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Research - HSE

Procedure

Contents

•	Purpose and Scope
•	Policy
•	Definitions
•	Method
•	Roles/responsibilities
•	Performance Standards/Monitoring

PURPOSE AND SCOPE

The purpose of the procedure is to ensure investigations are conducted and reported on in accordance with FOD policy. The principles apply across FOD. However, it is recognised that there are significant differences between the legal systems of Scotland, and England and Wales. Whenever possible, these are identified in the text, but if additional interpretation of legal matters is required then inspectors should consult the relevant enforcement handbook.

During all investigations, inspectors must:

(1)	consider all stages in the investigation process and conduct the investigation in accordance with the work instructions (WIs) and key activities (KAs) required by the particular circumstances of the incident being investigated. Each stage of the investigation is documented as a WI. The KAs which may be required during each stage are identified within each WI;
(2)	achieve the performance standards relevant to each required stage of the procedure;
(3)	be able to demonstrate that they have considered all stages and used those required by the particular circumstances.

Investigations will not always follow precisely the stage-by-stage process illustrated in Figure 1 [Not available]. Investigation is an iterative, not a linear process: it may be necessary to revisit earlier stages in the process. For example

(1)	after interviewing (WI 5), the objectives under planning could change requiring WI 1 to be revisited;
(2)	when assessing the evidence (WI 8) it may be identified that there is a need to re-interview witnesses (WI 5).

Many of the actions will be carried out together and at the same visit.

The principles of Enforcement Management Model (EMM) apply throughout the procedure. The arrangements for the systematic monitoring of the procedure mirror those for EMM. Key performance standards are identified for the purposes of systematic monitoring (see Appendix 1)

The procedure applies to the investigation of all types of incidents. It documents the core investigation process. Inspectors should apply the relevant supplementary procedure when conducting investigations on the topics below:

(1)	major incidents (as defined in OC 75/1);
(2)	FOD QS procedure - Complaints Investigation (in preparation)
(3)	incidents involving pesticides where there has been no report of a poisoning under Regulation 5(1) RIDDOR 1995 (see OC 301/9;
(4)	FOD QS procedure - Gas Investigation (in preparation);
(5)	statutory notifications of overexposure, release, spillage, loss or theft made under the Ionising Radiations Regulations 1999 (OC 560 series).

POLICY

It is FOD policy that investigations will be conducted in accordance with the principles of proportionality, consistency, targeting, transparency and accountability. In particular, investigations will be:

(1)	continued only so far as they are proportionate to the achievement of the objectives set for them (see para 2 below);
(2)	conducted and/or supervised by staff with suitable and relevant experience, training and expertise;
(3)	provided with adequate resources and support, including information, equipment and staffing;
(4)	conducted so that efficient and effective use is made of the resources committed to them;
(5)	timely, so far as this is within the control of the investigating inspector(s);
(6)	subject to suitable management procedures for monitoring the conduct and outcome of investigations;
(7)	conducted in accordance with FOD's obligations under Service First; and
(8)	conducted in conformity with the FOD Quality System procedure

The following factors will be relevant in determining whether an investigation continues to be proportionate:

(1)	public expectation, for example, where there has been a fatality or fatalities, serious ill health, or an incident involving multiple serious injuries;
(2)	the potential (taking account of reasonable foreseeability) for a repetition of the circumstances to result in a fatality or fatalities, serious ill health, or serious injuries, either in the activities of a specific dutyholder or within industry generally;
(3)	the extent to which the available evidence allows conclusions as to causation to be drawn and supported with sufficient certainty, including conclusions as to responsibility for alleged breaches of relevant legislation;
(4)	the value to HSE of the information to be gathered by the investigation, for example where new technology is involved;
(5)	the extent to which the resources needed for the investigation are disproportionate to the hazard(s) or risk(s);
(6)	the extent to which the continuation of any investigation conflicts with the developing priorities within a FOD division; and;(7) the prevalence of the event, either in the activities under the control of a specific dutyholder, or in an industry sector generally.

DEFINITIONS

Incident: includes events reportable under RIDDOR such as accidents dangerous occurrence and cases of industrial disease. (Purpose and scope defines circumstances where other procedures apply.)

Benchmark: the acceptable levels of risk determined by standards enforceable in law.

Evidence: information obtained in a legal enquiry to establish a fact or a point in dispute which must be admissible in court.

Investigation: the process of enquiring into the direct and contributory causes of an event with a view to HSE deciding on appropriate action.

Work instruction: this explains in more detail how to carry out the relevant part of the procedure.

CPI Act: Criminal Procedures and Investigations Act 1996. Parts I and II cover criminal investigations, and the retention and disclosure of prosecution material. OC 168/4 and OC 168/5 give practical guidance on provisions relevant to this procedure. In Scotland, separate legislation applies.

Dutyholder: an individual, body corporate or unincorporated, with duties under the HSW Act, other relevant statutory provisions, or other primary legislation.

Employee representatives: employees appointed under The Safety Representatives and Safety Committees Regulations 1977 or an elected representative under the Health and Safety (Consultation with Employees) Regulations 1996 - both sets of regulations are in file 111.

Expert help: individuals with knowledge and experience greater than an inspector in relation to an investigation who can offer help in determining the circumstances, causes and relevant benchmarks. Expert help can be provided by SG, TD, Employment Medical Advisory Service, Health and Safety Laboratory, external experts or more experienced colleagues.

PACE: Police and Criminal Evidence Act 1984. Inspectors in England and Wales are required to have regard to the Codes of Practice (file 168) made under PACE when collecting evidence in support of potential prosecutions. Further guidance on questioning suspects (Code C) or tape-recording interviews (Code E) is in the Enforcement Handbook - England and Wales Chapter 2. In Scotland, separate legislation applies.

METHOD

The following are the separate work instructions (WIs) of the investigation procedure. They are listed in the table in this paragraph, represented ... and are broken down into a number of key activities (KAs) which describe how each part is to be carried out. The circumstances of the investigation will determine which KAs are needed. If relevant, then the inspector should apply all the work instructions appropriate to the investigation being undertaken.

Click Below to access these Work Instructions and the Key Activities relating to each one

WI 1	Planning
WI 2	Preparation
WI 3	Conduct and liaison
WI 4	Establishing circumstances
WI 5	Interviewing
WI 6	Establishing physical evidence
WI 7	Gathering intelligence
WI 8	Assessment of evidence
WI 9	FOCUS recording and preparation of further reports

ROLES AND RESPONSIBILITIES

The DFO/FODMB should ensure sufficient resources are available throughout FOD to operate the investigation procedure.

The divisional director should provide sufficient resources to enable inspectors to carry out investigations in accordance with this procedure.

The head of operations should:

(1)	assist with difficult cases when necessary;
(2)	monitor the quality of a sample of investigations conducted by band 2s; and
(3)	review the monitoring undertaken by band 2s at least annually.

The Field Management Unit (FMU) band 2s are responsible for:

(1)	allocating resources once an incident is selected for investigation;
(2)	ensuring their band 3 and 4 inspectors apply the procedure and achieve performance standards which are appropriate to the circumstances of an investigation; and
(3)	carrying out monitoring as set out in performance standards and monitoring arrangements.

Band 3 and 4 inspectors should apply the investigation procedure to all investigation work and ensure they achieve relevant performance standards.

PERFORMANCE STANDARDS AND MONITORING ARRANGEMENTS

The tables in Appendix 1 list the performance standards for the investigation procedure. They are the measures which are used to judge whether the procedure is being followed and their achievement will demonstrate the rigour and effectiveness of investigative effort.

Inspectors should give appropriate consideration to and achieve all performance standards which are relevant to an investigation. Appendix 1 lists the KAs of each work instruction which are associated with most of the performance standards. Inspectors should carry out the relevant actions listed in these KAs. If a performance standard is not relevant or appropriate to an investigation, then inspectors need not give further consideration to that performance standard and its associated KA. If inspectors are unable to follow the procedure then they should discuss and record the reasons for this with their line manager.

Two forms of monitoring will be undertaken:

(1)	systematic monitoring of all fatal accidents, prosecutions and band 4 investigations; and
(2)	a sample of other investigations to be undertaken by the line manager during the first half and in the second half of the work year.

The investigations sampled should be the same as those selected under the sample monitoring arrangements for EMM.

Appendix 2 lists the arrangements for the systematic monitoring of investigations. Under such arrangements, the key performance standards highlighted in bold in Appendix 1, will be monitored. These key performance standards constitute the critical elements of the investigation procedure.

Line managers will carry out monitoring as defined by the table in Appendix 2 once an investigation is complete and prior to any decision to prosecute. The monitoring arrangements column in Appendix 1 is where they obtain the evidence to determine whether the necessary performance standards have been met. Investigating inspectors will submit this evidence to their line manager (as is current practice), with investigation/prosecution reports, including associated FOCUS entries (see WI 9). Discussions between line manager and inspector may be necessary as part of the monitoring process. They should record any significant discussions or decisions made following such a meeting.

For investigations not subject to the monitoring arrangements illustrated by Appendix 2, the investigating inspector does not have to submit the necessary evidence associated with the key performance standards to their line manager. Inspectors should record investigations in accordance with existing practice (see WI 9). Where FOCUS reports alone will not provide sufficient detail, for example if the investigation is particularly complex or liable to external scrutiny, an inspector should provide the level of reporting as detailed in WI 9, kA 2. This will demonstrate their achievement of the appropriate performance standards prior to any decisions on action.

When monitoring in accordance with Appendix 2 has been carried out, a keyword INVAPP (upper case) should be recorded on the FOCUS investigation summary record.

Appendix 1: Monitoring of the Work Instructions

Work Instruction 1	Planning
Work Instruction 2	Preparation
Work Instruction 3	Conduct and Liaison
Work Instruction 4	Establishing Circumstances
Work Instruction 5	Interviewing
Work Instruction 6	Establishing Physical Evidence
Work Instruction 7	Gathering Intelligence
Work Instruction 8	Assessment of Evidence
Work Instruction 9	Focus Reporting and Preparation of Further Reports

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Monitoring: Work Instruction 1 - Planning

Relevant Key Activity	PERFORMANCE STANDARD (to be met by investigating inspector)	Monitoring arrangements (to be conducted by line manager)
1	Establish the objectives of the investigation.	Discussions with line manager.
1	Ensure a timely conduct of the investigation (2 months).	FOCUS entries.
1	Allocate sufficient resources to ensure the expected objectives can be achieved.	Discussions with line manager.
1	Ensure the investigation complies with the HSE investigation policy, i.e. proportionality etc.	Discussions with line manager.
2	Verify the current status and details of the incident where appropriate.
3	Identify and contact interested parties where appropriate.	Discussions with line manager.
4	Ensure inspector's competence and experience are suitable for the investigation.	Discussions with line manager.
5	Direct or use an investigation by a dutyholder where appropriate.	FOCUS entries.

To see work Instruction 1, Click Here

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Monitoring: Work Instruction 2 - Preparation

Relevant Key Activity	PERFORMANCE STANDARD(to be met by investigating inspector)	Monitoring arrangements (to be conducted by line manager)
1	Identify relevant benchmarks before the investigation begins, or as soon as possible after the investigation commences.	FOCUS entries.
2	Liaise, if appropriate, within FOD and HSE.
3	Consider whether expert help is required.	SG Request, discussions with line manager.
3	Ensure the investigation complies with the HSE investigation policy, i.e. proportionality etc.	Discussions with line manager.
5	Obtain all necessary equipment.

To see work Instruction 2, Click Here

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Monitoring: Work Instruction 3 - Conduct and Liaison

Relevant Key Activity	PERFORMANCE STANDARD(to be met by investigating inspector)	Monitoring arrangements (to be conducted by line manager)
1	Commence enquiry within 2 weeks of receipt of F 2508.	Date of initial notification form or 2508 and FOCUS entries.
2	Contact dutyholders and their representatives as soon after arrival on site as possible.	FOCUS entries.
3	Contact those affected and witnesses as soon as practicable once investigation begins and about the outcome.	FOCUS entries.
4	Contact bereaved relatives as soon as possible following notification of incident.	FOCUS entries, letter with MISC199/MISC200 form enclosed.
5	Contact employees' representatives as soon after arrival on site as possible.	FOCUS entries.
8	Liaise with outside agencies but particularly the police following a fatal(s) if manslaughter or culpable homicide may be suspected.	Discussions with line manager.
10	Record information.	FOCUS entries, notebook, statements.

To see work Instruction 3, Click Here

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Monitoring: Work instruction 4: Establishing Circumstances

Relevant Key Activity	PERFORMANCE STANDARD(to be met by investigating inspector)	Monitoring arrangements (to be conducted by line manager)
1 and 2	Identify immediate and underlying causes	FOCUS entries.
1 and 2	Identify potential breaches of the law.	FOCUS entries.
1 and 2	Ensure appropriate remedial action has been taken, to prevent immediate reoccurrence.	SG Request, discussions with line manager.
2	Identify and follow up reasonable lines of enquiry.	FOCUS entries.

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Monitoring: Work Instruction 5 - Interviewing

Relevant Key Activity	PERFORMANCE STANDARD (to be met by investigating inspector)	Monitoring arrangements (to be conducted by line manager)
1	Prepare appropriately for interviews.
2	Interview in an appropriate order
3	Conduct interview in a professional manner.
4	Make appropriate records of interviews.	FOCUS entries. Inspector notebook entries.
5	Make appropriate use of any police interviews.
6	Arrange for joint interviews with other enforcing authorities where appropriate.

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Monitoring: Work Instruction 6 - Establishing Physical Evidence

Relevant Key Activity	PERFORMANCE STANDARD(to be met by investigating inspector)	Monitoring arrangements (to be conducted by line manager)
1	Identify and preserve physical evidence using appropriate powers as soon as possible once the investigation begins.	Photographs, samples, exhibits
2	Record factual details	FOCUS entries, inspector notebooks.
3	Recreate the circumstances of the incident where appropriate.	Photographs, videos.
4	Liaise with and use evidence collected by police/Home Office forensic scientists when appropriate.

To see work Instruction 6, Click Here

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Monitoring: Work Instruction 7 - Gathering Intelligence

Relevant Key Activity	PERFORMANCE STANDARD (to be met by investigating inspector)	Monitoring arrangements (to be conducted by line manager)
1	Disseminate information to sectors and other interested parties in HSE when appropriate.	Memos, FOCUS entries including drop-down screens.
2	Generate a SAPID if appropriate given the circumstances revealed by the investigation.	SAPID Form.

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Monitoring: Work Instruction 8 - Assessment of Evidence

Relevant Key Activity	PERFORMANCE STANDARD (to be met by investigating inspector)	Monitoring arrangements (to be conducted by line manager)
1 and 2	Assess evidence obtained and justify and record any subsequent decisions once sanctioned by the line manager.	Discussions with line manager, FOCUS entries and investigation reports.
4	Systematically apply EMM in accordance with Appendix 2	EMM proforma for recording key EMM outcomes and decisions.
4	Apply the principles of EMM in all other cases.	Discussions with line manager.

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Monitoring: Work Instruction 9 - Focus Reporting and Preparation of Reports

Relevant Key Activity	PERFORMANCE STANDARD(to be met by investigating inspector)	Monitoring arrangements (to be conducted by line manager)
1 and 2	Completion of investigation contacts and reports on FOCUS within 10 days of contact.	FOCUS entries and FOCUS data quality monitoring.
2	Completion of further reports within one month of completion of investigation.	Review of further reports by line manager. Discussions with line manager on outcome.

To see work Instruction 9, Click Here

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Appendix 2

Arrangement for the Monitoring of Investigations

	Band 1	Band 2	Band 3	Band 4
Fatal Accidents	All	All	All	N/A
Prosecutions	All	All	All	All
All Investigations	-	-	Sample	All

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Footnotes

Enforcement Management Model

You can read about HSE's Enforcement Management Model, by clicking here

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Procedures for the Investigation of ‘Major Incidents’
In April 2001, the HSE established new quality management arrangements’ for responding to, and investigating, ‘major incidents'. A Major incident is defined as:

'a significant event which demands a response beyond the routine. Significance is determined by the severity of the incident, the degree of public concern and the nature and extent of HSE's previous involvement with the duty holder(s); though the nature of previous involvement would not alone trigger a major incident investigation.'

The HSE says that this document "is one of a series of documents which establish procedures designed to meet HSE’s Enforcement Statement/Quality Statement for Continuing Aim 2 - To secure compliance with the law in line with the principles of proportionality, consistency, transparency and targeting on a risk-related basis."

To download this document, click here (PDF)

Perhaps the most interesting aspect of this new policy is that the new procedures requires that an investigation into HSE’s role prior to the ‘major incident' taking place. These investigations are called ‘Prior Role Inquiries’.
The policy says that:

"The nature and extent of the Prior Role Inquiry depends upon the seriousness and complexity of the incident. In more serious or complex incidents it will be necessary to form an inquiry team. This team is composed of people from outside the home Directorate with the necessary competence to undertake the field work for the inquiry under the direction of an inquiry team leader at Band 1 level. In less complex incidents it may be appropriate for the Band 1 to undertake the inquiry alone."

To find out more about the Prior Inquiry Reports, Click Here

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Page last updated on November 22, 2003