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Research - HSE

Prior Role Inquiries

The HSE document Major Incident Response and Investigation Policy and Procedures, published in April 2001, requires that a a 'Prior Role Inquiry' should be set up to look at the conduct of the HSE prior to the incident. These reports should be made public.

To see the Prior Inquiry Reports, click here.

To download the full document, click here (PDF)

Below is set out what this document says (appendix 4, page 30) the Prior role Inquiry should investigate and what the final report itself should contain.

The Investigation
"The Inquiry considers

Prior contact and advice given to the dutyholder(s) involved in the incident generally, and in particular at the site of the incident. This includes
information on:
- planned routine inspections;
- reactive inspections;
- safety reports;
- the granting of licensing and exemptions;

The extent and nature of contact and cooperation with other enforcing authorities etc in relation to the site or dutyholder(s) involved;
the time and resources spent on previous contacts with the dutyholder(s) and at the site, the topics addressed and the actions taken. How these activities were planned, monitored and closed out;
what inspection policy and resources are generally applied to the dutyholders of the type in question and whether they were applied at the site prior to the incident. This takes account of not only written instructions but also the operational procedures and practices normally adopted by HSE;
whether the previous enforcement activities were effective, the advice given was sufficient and the standards applied were adequate/ appropriate in the light of the resources available (where appropriate this includes an assessment of the effectiveness of the arrangements for liaison with other enforcing authorities);
whether the existing inspection policy and resources, procedures and instructions applied to HSE contact with dutyholders of the type involved were adequate, absent or deficient;
where there has been no previous contact with the site, whether such absence of contact was in line with OD inspection policies and procedures and if not how this situation arose;
what could be done differently to improve effectiveness"

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The Report

"The report records the findings of the inquiry into HSE's prior role. In the main these arise directly from HSE's contacts with the dutyholder(s) concerned. However the report deals also with the broader examination of the adequacy of HSE's arrangements for dealing with dutyholders of the type in question. The report includes:

The terms of reference for the inquiry;
An executive summary of key conclusions and proposals for action;
An account of the legal position at the site and with the dutyholder in question if their performance at other sites is relevant; for example any outstanding enforcement action, any relevant exemptions, licenses, safety cases, safety reports and contact with other enforcing authorities etc. This largely concentrates on factual matters which are directly relevant to the incident but includes enough information about the site/dutyholder in general to set the specifics in context;
A factual summary of HSE's previous contacts with the site/dutyholder/ other authorities, including visits, meetings, written and verbal advice given (were recorded on file). This should concentrate on the incident but set the information in context;
Analysis of the issues covered in the previous paragraphs exploring whether HSE's approach is being coherent, based on sensible risk related priorities, reflecting any known strengths and weaknesses of that site/dutyholder, making reasonable use of the resources available to HSE, being technically sound and in accordance with HSE policy and procedures including the HSC Enforcement Policy Statement;
An assessment of HSE's approach generally to dutyholders of the type involved, including inspection, policy and local and Directorate/ Divisional resourcing. Sources for this should include both written material (instructions to inspectors, technical guidance etc) and actual but undocumented practices;
Where relevant the role of the Commission/Executive/Board in their exercise of leadership, direction and oversight of operational policy relevant to HSE's general approach to dutyholders of the type involved;

Any lessons to be learned including:

Allocation of responsibilities within the Directorate and/or HSE
Resourcing and inspection priorities
Adequacy of existing relevant HSE/Directorate procedures or instructions or where the absence of such procedures/instructions was relevant.
Changes to methods for contacting and influencing such
Other relevant issues such as support training for
inspectors, effectiveness of arrangements for liaison with
other enforcing authorities etc."

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ior Role Reports

At present there is only one report that is publicly available.

Inquiry into Train Crash at Ladbroke Grove

The following Reports are under preparation

• Train Crash at Hatfield

• Deaths at Port Talbot

• Train Crash at Potters Bar

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Page last updated on June 9, 2003