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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
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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;
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The
extent and nature of contact and cooperation with
other enforcing authorities etc in relation to
the site or dutyholder(s) involved; |
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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; |
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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; |
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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); |
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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; |
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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; |
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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:
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The
terms of reference for the inquiry; |
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An
executive summary of key conclusions and proposals
for action; |
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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; |
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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; |
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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; |
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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; |
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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; |
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Any
lessons to be learned including:
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Allocation
of responsibilities within the Directorate
and/or HSE |
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Resourcing
and inspection priorities |
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Adequacy
of existing relevant HSE/Directorate procedures
or instructions or where the absence of
such procedures/instructions was relevant. |
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Changes
to methods for contacting and influencing
such
dutyholders. |
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Other
relevant issues such as support training
for
inspectors, effectiveness of arrangements
for liaison with
other enforcing authorities etc." |
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Prior
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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