Conclusion: Inspections

Balancing Inspections with Investigations
Who is inspected?
Importance of Inspections

At the end of 2001, there were 419 FOD field inspectors and 736,000 registered premises: one inspector to 1700 premises. Even if inspectors did nothing other than undertaking preventative inspections, most workplaces would not receive an annual visit from an inspector. However, the reality is that, in addition to undertaking inspections, inspectors have to conduct investigations – which may comprise many visits to a particular workplace - as well as prepare cases for prosecutions. It is therefore hardly surprising that each year, FOD inspectors can only undertake a relatively small number of inspections.

Chapter one shows that in the last five years there has been a 41% decline in the number of ‘contacts’ involving inspections – a reduction from 117,156 in 1996/7 to 68,857 in 2000/01. The audit also shows that in 2000/01, only 40,237 out of the 736,000 total registered premises received an inspection – one premises in 20. On average a construction site can expect one visit every ten years.

The decline is particularly significant since a recent independent research report funded by the HSE concluded that that:

"Inspection is an effective means of securing employer compliance. If targeted at key groups, it can bring about significant improvements in health and safety performance, both in terms of ensuring control measures are effective and, at least according to the general literature (rather than specific HSE literature), securing improvements in employees’ health and safety."

Why has there been such a decline in the number of inspections? The immediate cause – as shown in chapter one - is an increase in the number of inspector contacts involving investigations into reported incidents (an increase in the same time period of 43.5% from 39,384 to 56,515). However, such a reduction would not be necessary if the HSE was adequately resourced: during the years under consideration, the HSE simply did not have the money to employ a sufficient number of inspectors to ensure that, as levels of investigations increased, there was no decline in the levels of inspections.

The decline in inspector contacts indicates how finely balanced are HSE resources. An increase in one core activity of inspectors has to result in a reduction of another core activity.

Balancing Inspections with Investigations
However putting the question of resources to one side, the decline in inspector numbers raises an important question which goes to the heart of HSE’s operational activities. Was FOD right to have prioritised investigations over inspections?

This is a very difficult question to answer. Undoubtedly, both inspections and investigations are important, but no research has been undertaken which assesses the relative effectiveness of one compared to the other.

The HSE has historically prioritised inspections. The reason for this is linked to its perception of itself as organisation concerned principally with ‘preventing death and injury’ rather than one concerned with ‘accountability’. It is better to prevent a death or injury rather than simply responding to these incidents when they happen. This has resulted in an emphasis on inspections rather than investigations as the latter - in contrast to the former - are seen as principally concerned with ‘accountability’, not ‘prevention’.

The only rationale that the HSE has given for the increase in the number of investigations is contained in the evidence it gave in 1999 to a Parliamentary Select Committee. It stated:

"There is some public expectation that HSE should investigate more accidents, because accidents which are not investigated may result in potential offenders escaping punishment."

In saying this, the HSE was aware that this would impact upon its inspection programme.

"At present HSE plans to increase the number of investigations from 1999-2000 to 2001-02 by about 3 per cent. But any major increase beyond that would seriously reduce the number of preventative inspections and detract from the primary objective of ensuring that risks are properly controlled and that incidents do not occur. HSE believes that a balanced programme … is needed to secure improvements in health and safety on a continuing basis. The balance of inspection and investigation work has to be kept under continuing review."

In its final report, the Select Committee concluded:

"We agree that the HSE's focus should remain largely preventative. However, we are disappointed by the low levels of investigation …. We therefore support the proposed target of a three per cent increase in investigation of reported injuries over the next three years. However, this target must be taken seriously: it should not be viewed as merely 'aspirational'. If resources are not currently available to allow the HSE to make this improvement, they must be provided."

Although. it is not clear whether the Select Committee was aware of the consequences of an increase in HSE’s investigation levels, it is interesting that both the HSE and the Select Committee have only one reason for increasing investigations – that is to increase accountability.

It is certainly correct to say that an important element of investigations is ‘criminal accountability’ – something which is generally absent in relation to inspections. Whilst inspections can reveal circumstances that justify a prosecution, the absence of harm usually make it inappropriate for prosecutions to take place unless the risk of endangerment or failure is very high. This is because the criminal justice system generally deals with offences involving harm, and experience has shown that courts take prosecutions less seriously where no harm has been caused. As a result inspections have a primarily preventative function. However, since most investigations concern ‘harm’, or circumstances where a high risk of harm is reported to have existed, an important purpose of investigations – over and above their preventative function – is to ensure that consideration is given to criminal accountability issues. Unless investigations take place, organisations and individuals escape the possibility of prosecution.

However, it is wrong to suggest – which both the HSE and the Select Committee appear to do – that investigations do not have a strong preventative function. An important part of any investigation must be to rectify the circumstances that resulted in the harm (or, in the case of a dangerous occurrence, that resulted in the risk of harm) occurring in the first place. At the very least an investigation should ensure that any future risk of a similar incident taking place is very low. The absence of an investigation will mean that a risk of a repeat incident will continue to exist.

In addition, it is also the case that investigations can fulfill a preventative role in a more targeted fashion than inspections. The identity of the premises that will be inspected is determined by a ‘hazard rating’ that is given to it at a previous inspection (see below). This prior inspection may have taken place quite some time earlier and may not be an accurate reflection of the company’s level of safety at the time of the subsequent visit. Time spent on some inspections may as a result not be that useful.

In contrast, investigations takes place in relation to a particular incident that has just occurred. A report of such an injury indicates that unsafe or illegal practices may exist in relation to a particular workplace. Of course this is not necessarily the case. A death or injury may have occurred where the premises were faultless and conversely a dangerous premises may never have a reportable incident or injury. Yet since it must be the case that deaths or injuries are more likely to occur in unsafe workplaces (for if this wasn’t so, there would be no point in trying to improve workplace safety conditions) the very fact of a reported incident is important upto date intelligence that there are issues of safety that need to be considered.

This point is even stronger in relation to reported ‘dangerous occurrences’. Unlike a report of an injury (which may well not, as suggested above, be the result of unsafe or illegal conditions) a report of a ‘dangerous occurrence’ – like the collapse of a scaffold or contact with overhead power lines - indicates that a situation has in fact arisen which is unsafe and dangerous and most probably a breach of health and safety law. The situation needs immediate rectification.

It is often argued that an inspection that results in changes in working practices that prevents a major injury or death must be far more important than any investigation into a death or injury that has already taken place. Put like that, and if there is simply a choice between the two, this is an unarguable point. Why wait to investigate deaths or injuries when you can prevent them?
However, in practice this is not the choice that inspectors have to make. Even when an inspection does result in identified dangerous practices being halted, it is never known whether those dangerous practices would – had they continued to have existed - actually have caused a death or injury. It is only possible to say that had these practices not been stopped, there would continue to have been a significant risk of harm. What the inspection did was to reduce the risk of harm existing but not necessarily preventing any death or injury actually taking place.

Inspections, as with investigations reduce future risks of death and injury – not stop them happening. What investigations can do in addition is to ensure that those organisations and individuals that have committed criminal offences that deserve prosecution be held accountable.

The purpose of the above discussion is not intended to argue that the number of inspections should be reduced even more to allow for more investigations or indeed that the HSE have got the balance right. This report is in no position to suggest what – in the context of HSE’s current financial circumstances – should be the appropriate balance between inspections and investigations. It is our contention that the HSE should simply not have to be in a position to choose between one of its two core activities in the way that it has been forced to so.
It is important, however, that the HSE recognises the value of investigations over and above that of ensuring ‘accountability’ and that any decision about redrawing the balance should not be based on an inaccurate view that an increase in investigations will only result in increased accountability and not prevention.

Also, for the sake of transparency, the HSE should spell out more clearly to the public:
• its rationale for any decision to increase the level of investigations;
• the effect that this will have on its other activities;
• if lack of resources is the reason for a reduction in a code activity.

A particular problem faced by the HSE in making choices about priorities is that it has not commissioned any research – or at least published it - into the effectiveness of its inspection and investigation regimes. It is therefore difficult for the HSE to know what are the positive benefits of an increase in investigations, on the one hand, or an increase in inspections, on the other, and what will be the effects of reducing one at the expense of the other.

Who is inspected?
Whilst the level of inspection is important – it is also important to consider which premises have been subjected to inspection. FOD inspectors could, for example, have a high level of inspection, but fail to inspect the most hazardous premises: alternatively, inspectors could have a low level of inspection, but visit all the most hazardous plants.

During the whole of the five year period under analysis, FOD has run an ‘inspection rating procedure’ in which all premises, when inspected, are rated from 1 to 6 or 1 to 4, according to a number of criteria: "competence and attitude of management", "welfare compliance gap", "safety Rating" and ‘health rating’. These numbers are then added up and a final ‘hazard rating’ number is obtained.

In April of each year, the identity of those premises which have the highest ‘hazard rating’ (falling into what is known as ‘category ‘A’ – high Hazard’) are made known to the principal inspectors around the country who give them priority in the following year’s inspection plan. Inspectors will then decide what additional premises should be inspected by considering a number of factors including, the hazard ratings of premises, the particular priorities of FOD at that time, and other local factors.

The data we have obtained from the HSE does not allow any proper assessment of this rating system - but our analyis does raise some questions about its effectiveness. This is because, for example, out of all the industry groups, the one with the biggest decrease, in the level of inspections is in construction – a reduction of 52% from 37,774 in 1996/7 to 17,908 in 2000/01. One would imagine that the hazard rating system would ensure that any necessary reduction in inspection numbers would impact less on the construction industry than other industries since it has a historically high level of death and injury and is well known to be particularly hazardous.

The problem with the current rating system is that:

Importance of Inspections
Inspections do provide an opportunity for the HSE to monitor workplaces in a way that investigations cannot.