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Work
Instruction 4:
Preperation:
Establishing Circumstances
This work instruction states that "Inspectors
must collect sufficient information and potential
evidence to ensure the given objectives of the investigation
are achieved. This will enable:
| (1) |
identification
of immediate and underlying causes |
| (2) |
identification of potential breaches of the law; |
| (3) |
inspectors to ensure appropriate remedial action
has been taken to prevent a reoccurrence; |
| (4)
|
identification
of reasonable lines of enquiry; |
| (5) |
the making of decisions about appropriate action
or further investigation; |
| (6)
|
HSE
to gain knowledge of the causes of incidents. |
In
order to achieve this there are two key activities.which
describe how to establish the circumstances during
an investigation.
Key
activity 1
ON-SITE INVESTIGATION METHODS
| 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. |
|
| 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. |
| 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. |
| 5 |
During
an investigation, inspectors should be aware of
other potential breaches not related directly
to the investigation and consider enforcement
action where appropriate. |
| 6 |
Inspectors
should carefully analyse information collected
during an investigation to:
| (1) |
facilitate
further investigation |
| (2) |
Co-ordinate
the investigative activities; |
| (3) |
counteract any investigator bias; |
| (4) |
verify
the investigation findings; and |
| (5) |
identify
root causes, including failings in the management
of health and safety. |
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Key activity 2
IDENTIFICATION AND FOLLOW-UP OF ALL REASONABLE LINES
OF ENQUIRY
| 7 |
Investigating
inspectors should identify, and eliminate or confirm,
all reasonable lines of enquiry relevant to the
objectives of an investigation. |
| 8 |
Inspectors could apply an analytical investigation
technique, when appropriate, and when time and
resources allow, to help identify reasonable lines
of enquiry. See HS(G)65 Appendix 5 Analysing the
causes of accidents and incidents of which the
appendix to this WI gives an
overview. |
| 9 |
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. |
| 10 |
Inspectors
should follow up individual lines of enquiry to
the extent that is necessary to:
| (1) |
confirm
or rule out their significance; |
| (2) |
where
appropriate, establish facts beyond reasonable
doubt; |
| (3) |
justify and support enforcement action resulting
from the investigation; |
| (4) |
determine
causation;; and |
| (5) |
satisfy, where possible, those immediately
affected and public interest. |
|
| 11 |
Inspectors
should keep appropriate records of lines of enquiry
considered, particularly those eliminated, and
the basis for relevant decisions. |
| 12 |
In
many investigations identification of all reasonable
lines of enquiry will be relatively straightforward.
Other cases will be more complex, for example
when the cause of a plant failure is not immediately
apparent, or a complex chain of events has to
be unravelled. Reasonable lines of enquiry can
be identified by:
| (1) |
interviewing witnesses; |
| (2) |
application of the individual knowledge
and experience of the investigating inspector(s); |
| (3) |
comparing actual risk against a relevant
benchmark; |
| (4) |
utilising
expert help; |
| (5) |
use
of an analytical investigation technique; |
| (6) |
discussions
with colleagues; and |
| (7) |
considering the theories, suggestions and
explanations offered by the witnesses, dutyholder(s),
employees or their representatives. |
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| 13 |
Where
there are reasons for eliminating any line of
enquiry, inspectors should record this in such
detail as is appropriate to the circumstances.
If inspectors anticipate legal proceedings,
any expert witness who has discounted a line
of enquiry should include reference to it, and
their reasoning, in a statement of expert opinion.
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APPENDIX
(WI 4, para 8)
A GUIDE FOR INSPECTORS USING HS(G)65 (APPENDIX 5)
INCIDENT INVESTIGATION TECHNIQUE
| (1) |
HS(G)65
Appendix 5 can be used as a framework and
guide for the analysis of the immediate and underlying
causes of events. It is based on the 3-level model
in HS(G)65 which describes health and safety management
as consisting of 3 components:(1) Level 3 - workplace
precautions - ie those things at the point of
risk which prevent injury and ill health. Workplace
precautions can be described generically as made
up of premises, plant and substances, procedures
(or methods of work), and people; |
| (2) |
Level
2 - risk control systems - ie the mechanisms or
systems for ensuring adequate workplace precautions
are provided and maintained; |
| (3) |
Level 1 - management arrangements - ie the management
activity for organising, planning, control and
monitoring of the design and implementation of
risk control systems.
The analytical process described in Appendix 5
can be used to systematically plan and analyse
an investigation by examining the potential influence
of each component of all 3 levels. |
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