Investigations
As noted elsewhere, this audit shows that the reduction
in the levels of inspection has gone hand in hand with
an increase in the number of investigation contacts.
Although the number of investigation contacts by inspectors
has risen by 43.5%, Chapter Two shows that the numbers
of actual incidents investigated has not risen by anything
near that number. The percentages of investigations
into:
• deaths of workers has risen from 88% to 98%.
• deaths of members of the public has risen from
52% to 92%.
• major injuries to workers has risen from 10.8%
to 19.3%.
• major injuries to the members of the public has
risen from 2% to 7.2%
• dangerous occurrences has risen from 26% to 31%
• over-three day injuries has risen from 2.6% to
4.5%
Although the increase in investigation levels since
1996/7 is certainly notable, very large numbers of major
injuries and dangerous occurrences – 80% and 69%
respectively - remain uninvestigated. Since the purpose
of investigations – as set out above - is to stop
any recurrence and to obtain criminal accountability,
this failure to investigate such a high number of investigations
must be of concern.
Investigation Criteria
This level of lack of investigation, however, may not
be so serious if it can be shown that those injuries
that are not investigated are neither very serious (even
though they are formally called ‘major’) nor
took place in circumstances where an investigation would
be possible or very helpful.
This raises the question of what systems the HSE has
to determine which of the thousands of reported incidents
should be investigated.
In the first four years of our audit, between 1996/7
- 1999/2000, FOD inspectors were supposed to follow
a document called "Selection of Accidents for Investigation"
(See box). This stated that the following incidents
should always be investigated:
• all "fatalities";
• all incidents which "would give rise, or
already have given rise to serious public concern";
and
•"very serious injuries".
The document went on to state that "exceptionally
serious injuries" should generally be investigated
– though it does not say how these injuries differ
from the "very serious injuries" that should
always be investigated.
The document stated that a principal inspector had discretion
to investigate "other accidents" such as those
which "appear to indicate a serious breach of the
law, accidents to young persons or children, or those
which recur at a particular premises or in a particular
industry". In deciding which of these to investigate
the inspector should take into account a number of factors
including "the severity or potential severity of
the injury" and "the gravity of any apparent
breach of legislation".
This policy had the following problems:
| • |
it
gave the Principal Inspector a great deal of discretion
in deciding which injuries or incidents to investigate; |
| • |
it
did not define the difference between a "very
serious injury" and an "exceptionally
serious injury" and indeed whether particular
forms of injury – like amputations or burns
- did or did not fall into those categories; |
| • |
it
did not mention ‘dangerous occurrences’
or ‘industrial diseases’ and therefore
did clarify how a principal inspector should treat
them in contrast to a major injury; |
| • |
it
did not give weight to any of the factors that
inspectors should consider when deciding which
of the "other accidents" it should investigate. |
The defects in this policy are reflected in the statistics.
For example, in the four years between 1996/7 to 1999/00,
for example, only 41% of the 4533 amputations and
43% of the 817 poisonings/asphyxias were investigated.
In its 1999 report, the Parliamentary Select Committee
criticised HSE’s injury selection policy. It
stated:
"we
continue to have some concerns about how the criteria
which determine which injuries will be investigated,
are applied by HSE inspectors. Decisions in the
past appear to have been unduly dictated by availability
of resources. While the HSE needs to operate within
its resource limitations, we believe that it should
develop more detailed guidance for inspectors. In
particular, more thought should be given to a) how
to 'weight' the criteria, since some should surely
have more influence than others and b) whether some
categories of very serious injuries should automatically
trigger an investigation in the same way that fatalities
do. Such a system would mean that decisions on whether
to investigate would be more rigorously based and
more transparent which would ultimately lead to
a greater consistency in application between inspectors.
We urge the HSE to use its review to address these
issues."
Following
this criticism, in April 2000, FOD piloted a new investigation
criteria policy – which has now been formally
approved throughout the HSE (see Appendix 2). In summary,
this states that inspectors should investigate the
following incidents:
| • |
all
deaths 'arising out of or in connection with work
activities' unless they involve suicides or deaths
from natural causes; |
| • |
all
reports of cases of industrial disease; |
| • |
certain
specified 'major injuries' relating to either
the injury caused (e.g. amputations) or the kind
of incident which resulted in the injury (e.g.
resulting from transport incidents) |
| • |
incidents
that are "likely to give rise to serious
public concern"; |
| • |
incidents
where there is "likely to have been a serious
breach of health and safety
law"; |
The policy states that when an investigation is not
possible because of "inadequate resources"
or "policy development", the incident "must
be referred to the Head of Operations". The policy
also allows an investigation not to go ahead due to
investigations when it is "impracticable"
or where there is "no reasonable practicable
precautions available for risk reduction".
This new policy is an improvement on the previous
one. It sets out much more clearly the criteria for
which incidents should be investigated. However, a
number of points should be made about it:
| • |
the
HSE has not provided any rationale as to why injuries
resulting from certain types of incidents (like
transport) must be investigated whilst others
(like the "collapse of a scaffold" or
an "explosion") should not be required
to be investigated. |
| • |
the
injuries mentioned do not directly match the way
injuries are categorised on the form (the ‘RIDDOR’
form) on which employers report an injury. This
will make it difficult for a Principal Inspector
to determine whether a particular injury recorded
on the form is in fact an injury that should be
investigated or not. For example, it is unlikely
that an inspector will know from reading the form
whether a person has suffered ‘scalping’
or burn injuries covering "10% of the body"; |
| • |
it
makes no explicit reference to ‘dangerous
occurrences’. |
FOD has in fact employed this policy in 2000/01 -
the final year of our data analysis. Has this policy
been implemented? Since, the categories in the new
policy do not entirely reflect the RIDDOR form, the
data provided to us by the HSE only allows a partial
assessment. However, the box below does indicates
that FOD is a long way from implementing the policy.
For example, although the new policy requires them
to have done so, FOD did not investigate:
• 12 out of 55 amputations of either hand, arm,
foot or leg;
• 337 out of 633 injuries resulting from
contact with moving vehicles ;
• 69 out of 178 injuries involving electricity;
• 569 out of 1384 falls from a height of over
2 metres;
• 1327 out of 2396 industrial diseases;
The Following injuries in the new investigation criteria
should all have been investigated in 2000/01 Level
of implementation by FOD of its selection criteria
in relation to ‘worker’ injuries. Click
Here
It is important to note that this audit does not consider
the quality or rigor of investigations that are undertaken
by the inspectors. It is interesting to note, however,
that between 1996/7 and 2000/01 the increase in the
number of investigation contacts (43.5%) is much greater
than the increases in the number of actual incidents
investigated. This would indicate that each investigation
in 2000/01 comprises more investigation contacts and
is therefore more rigorous than those that took place
in 1996/7. However our analysis does not look at increases
in the number of complaints investigated which may
at least in partexplain this increase.
It is also important to note that the HSE has recently
published new investigation procedures that are intended
to improve the quality of investigations and have
started a new training programme for inspectors (see
Appendix 3).
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