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ACCIDENT
INVESTIGATION
&REPORTING
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Fire Precautions
Fire Precautions :-
If continuous alarm sounds leave the building by the nearest exit
Report to the tutor at the assembly point
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INTRODUCTION
Tea / coffee facilities
Toilets
No smoking
First aid / fire
Mobile phone / pagers
Trainee introductions
Please ask questions at any time
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OVERALL AIMS
An understanding of the process andpurpose of investigating incidents
Remember : Includes ill health as well asinjury accidents
An understanding of the legal and
organisational requirementsfor recording and reporting
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2003/04 Statistics
235 fatalities
159,809 RIDDOR reported injuries
An estimated 2.2 million people sufferingfrom an illness caused or made worse bytheir current or past work
An estimated 39 million working days lost -30 million due to ill health & 9 million dueto injury
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The Reporting of Injuries,Diseases and dangerous
Occurrences Regulations(RIDDOR) 1995
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Whats the point of RIDDOR?
HSE/EHO need to know about the moreserious accidents, diseases anddangerous occurrences at work so they
can perform their statutory role.
They can analyse where and how risksarise and then investigate/enforce.
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What needs to be reported? Death or major injury:
employee or a self-employed person working onyour premises is killed or suffers a major injury(including violence), or;
a member of public is killed or taken to hospital
Over-3-day-injury: employee/self-employed off work, or incapacitated
for normal work for more than 3 days;
Disease: doctor notifies you of reportable work-relateddisease;
Dangerous occurrence: categories of near-misses.
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The Reporting of Injuries, Diseases and
Dangerous Occurrences Regulations
(RIDDOR) 1995 Reportingprocedures cover:
fatalities and major
injuries incapacity to work
for more than threedays
specified diseases
dangerousoccurrences2.1
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RIDDOR
Covers:
employers
employees self-employed
trainees
other people injured onpremises
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RIDDOR
Major injuries include:
fracture of: skull, spine, pelvis
arm, leg, wrist, ankle
amputation through any bone
loss of sight (temporary or
permanent
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RIDDOR
Major injuries(continued):
certain eye injuries
electric shock requiring attention
unconsciousness through lackof oxygen
acute illness due to exposure tocertain materials
hospitalisation for more than24 hours
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RIDDOR
Reportable occurrences:
structural collapses
fires and explosions
release of gases or other dangeroussubstances
failure of breathing apparatus while in use
scaffold collapse
contact with or arcing of overhead cables
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RIDDOR
Reportable diseases:
any disease listed in theregulations as reportable
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Social Security Act 1975 andRIDDOR
Every accident involving personal injury to anemployee must be entered in the accidentbook by:
the employee, or
someone acting on behalf of the employee
The accident book must be kept accessible.
An employer must investigate all accidents reported
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Reporting to enforcingauthorities
Since 01 April 2001, you can report accidents andoccurrences to the Incident Contact Centre by:
telephone
fax e-mail
post
Reporting accidents and occurrences direct to the localHSE Office, on Form F.2508 or F.2508A, is stillacceptable.
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Report to enforcing authorities
F.2508 must be sent to the enforcingauthorities in cases of:
injury at work resulting in more than three consecutivedays incapacity
death of an employee within one year of sustaining areportable injury
a reportable disease when diagnosed by a registeredmedical practitioner
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RIDDOR: Answers
Details of employee injury (normal
working Monday to Friday 8.00 am to 5.00pm)
Days off work Hrs in hospital Tick if RIDDOR applies
1 Sprained arm(put on light duty
with 5 days offnormal job)
1 day Nil
The light duty counts as 5 daysoff work
2 Broken arm30days 4 hrs
Any fracture but not toes andfingers
3 Broken finger 1 day 3 hrs No
4 Broken finger 4
days
3 hrs This is because of more than3 days off work
5 Dermatitis 1 day Nil Only if confirmed by doctor
6 Sprained ankle on Thursday,returns to work on Tuesday
2 daysNil
4 days not available for work(includes Sat and Sun)
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RIDDOR: Answers
Details of employee injury (normal workingMonday to Friday 8.00 am to 5.00 pm)
Days off work Hrs inhospital Tick if RIDDOR applies
7 Amputation of finger 2 days 6 hrs
Any amputation
8 Vibration white finger nil nil Only if confirmed by adoctor
9 Twisted ankle 4 days nil 3 days or more off work
10 Twisted ankle 1 days 3 hrs No
11 Electric shock (not unconscious) 2 days nil No
12 Electric shock (unconscious) 2 days 25 hrs Unconscious-ness
13 Electrical fault causing fire but workshop outof use for only 24 hours
N/A N/A
14 6 metre high scaffold collapses N/A N/A Over 5 metreshigh
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Accident/Incident Investigation
RIDDOR only requires reporting ofincidents etc.
No explicit legal requirement in any H&Slegislation to investigate - therefore WHYDO IT?
?
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?
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Accident/Incident Investigation
HSW Act states - employers mustensure.the health, safety and welfare of
employees... etc.
Reactive monitoring - to prevent the sameor similar from happening again
Review/revise risk assessments andassociated H&S documentation/workingpractices
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Are you learning
the lessons?
?
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Do you investigate incidents &
accidents in your company?
Do you do it well?
Do you find the underlying causes?
Do you take corrective action?
Do you review your risk assessments as a
result?
Do you do it?
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Accident Investigation Law
Explicit legal duty to investigate accidents
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HSE on Accident Investigation 1999
Most accidents are not investigated safety specialists lead rather
than line managers
effort determined by severity of the injuryrather than potential of the event
little employee involvement
if line managers do investigate, little trainingin investigation skills and techniques
immediate technical causes only
contd
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Integrated approach to accident investigation and riskassessment
ie it should be integrated but usually isnt!!
from HSE CD169/2001
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Integrated approach to accident investigation and riskassessment
ie it should be integrated but usually isnt !!
from HSE CD169/2001
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Team based investigation
RoSPA study - best practice
led by senior managers
involving employees, includingsafety representatives
supported by OS&H professionals acting
as facilitators
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Team based investigation
Local knowledge, especially operational
Building of trust;
Creates workforce 'champions' for H&S;
Check on safety management standards
Investigation of lower risk safety issues isimportant in creating a positive climate for more
structured investigation when major safetyfailures occur.
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Humane
Prevent suffering and maintain quality of life
No-one should be expected to risk life andlimb in return for a contract of employment
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The true cost of an accident
To the victim:
pain and suffering extra cost, less income
continued disability
incapacity for job and other activities the effects on others
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The true cost of an accident
To those responsible:
worry and stress
recrimination and guilt extra work
a) reports
b) staff replacement loss of credibility
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Is good health &
safety goodbusiness?
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The true cost of an accident
To the firm:
lost working time
a) the victim
b) others
damaged equipment
insurance costs
prosecution or civilaction
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We recognise the importance of costing
loss events as part of total safetymanagement. Good safety is goodbusiness
Dr. J Whiston, ICI Group SHE Manager
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Safety is, without doubt, the most crucial
investment we can make, and thequestion is not what it costs us, butwhat it saves.
Robert McKee, Chairman Conoco (UK) Ltd.
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Prevention is not only better, but cheaper
than cureProfits and safety are not in
competition. On the contrary, safety atwork is good business.
Basil Butler, MD British Petroleum plc
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We saved 750,000 on insurance
premiums through improving oursystematic management of health andsafety.
Birse Group plc
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Accident Costs Iceberg
Uninsured Costs
Insurance Costs
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Insurance Costs
Employers Liability
Public Liability Product Liability
Motor Vehicle
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Uninsured Costs
Product and material damage Lost production time
Legal costs
Overtime & temporary labour
Investigation time/Administration
Supervisors time
Fines
Loss of expertise/experience
Loss of morale
Bad publicity
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Grangemouth
BP refinery fire in 1987
One person died
Cost 50 million in property damage
Cost further 50 million due to businessinterruption
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HSE Example
Small engineering firm (15 workers)
Workers sleeve caught on rotating drill
Both bones in lower arm broken
12 days in hospital
Off work for 3 months
Admin duties for 5 months
Unable to operate machinery for 8 months
Managing Director Prosecuted
2 employees made redundant to prevent
company going out of business
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Costs to Company
Wages for injured worker over period =
Lost production/remedial work required =
Overtime wages to cover lost production =Wages for replacement worker =
Loss of time of manager/MD =
Legal expenses =
Fines and court costs =Increase in Insurance Premiums =
10000
8000
30007000
4000
3000
40006000
Total cost to business = 45000
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Costs of slips and trips in GB
To the individual
Lost income, pain, reduced quality of life
To employers over 500m p.a.Damages, admin. and insurance, lost
production, temporary absences
To society over 800m p.a.Loss of potential output, medical costs, social
security.
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What contributes to the slip /trip risk?
Floor
Environment
Slip/tripPotential
Contamination
Obstacles
People Footwear
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Unsafe people
Unsafe conditions
Accidents
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Some common causes
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Some common causesof accidents
Not using:
guards, scaffolds, platforms, etc.
Ignoring or disregarding:
warning signs
statutory notices
Untidiness or carelessness
Horseplay
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Safety in the workplace requires
Safe systems of work and goodorganisation
Good defect reporting and maintenance
arrangements
Careful, safety-based work planning
The correct tools and equipment for the jobin hand
contd
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Safety in the workplace requires
Knowledge of, and compliance with, safetylaw
Adequate information, training, instructionand supervision
Common sense and a mature attitude
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Reporting accidents
An accident book should beavailable in all work situations
The Reporting of Injuries,Diseases and DangerousOccurrences Regulations 1995
reportable injuries
three days or more off work
certain listed injuries
No report: no proof
no future safeguard
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THE LAW AND
HEALTH & SAFETY
Oberon: This is thy negligence - thou mistakest orelse commitst thy knavery wilfully
Shakespeare
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UK legal system
By HSE or LA
Leads to afine/imprisonment
Not insurable
Criminal
By injured person
Leads to award ofdamages
Must be insured
Civil
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EXERCISEYou are going to work by bus. You buy a ticket (a
contract with the bus co). During the journey,
the driver collides with another vehicle and you
suffer minor cuts and bruises. By the timeeverything is sorted out, you are very late forwork. You sprint from the bus stop and trip
over a paving stone,breaking your arm.
Who is, if anybody,
is liable for your injuries?
COMMON & STATUTE LAW
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COMMON & STATUTE LAWCommon law is unwritten being derived from local & customary
laws and the decisions of judges but is nevertheless binding
It evolves continuously as precedents are established
decisions of a lower court can be overturned by a higher court
Statute law is passed by Parliament, approved by the Sovereign &is written (published law)
It takes precedent over all other forms of Law (Common Law)etc
Some Statute law is derived from decisions of the European
Union (Directives etc)
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NEGLIGENCE
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NEGLIGENCE Donoghue v Stevenson (1932)must take reasonable care
to avoid acts/omissions which you can reasonably foreseewould be likely toinjure your neighbour
This duty of care is owedto people who are closely &directly affected by your acts/omissions (e.g. employers,
employees, contractors, visitors, suppliers)
defences against actions include: no duty owed, duty notbreached, breach did not lead to damage, risk accepted
voluntarily,contributory negligence
Bradford vs Robinsons Rentals (1967): employer liable
for reasonably foreseeable frostbite injuries to B
SAFE SYSTEM OF WORK
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SAFE SYSTEM OF WORK
Wilson & Clyde Coal v English 1938Aleading case which established anEmployers duty of care towards
employees Masters duty to a Servant
Safe premises
Safe plant & equipment
Competent fellow workers
Adequate supervision
(cf Health & Safety at Work etc Act)
BREACH OF STATUTORY
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BREACH OF STATUTORYDUTY
Damages can be recovered if it can be proved thatloss occurred because of the defendants failure tocomply with a statutory requirement
May be easier to prove than negligence, especiallyif the breach has been established by a criminalprosecution
Main defences: duty not breached, injured partynot protected by statute, harm not of type statutedesigned to protect, contributory negligence
Some statutory duties are absolute
VICARIOUS LIABILITY
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VICARIOUS LIABILITY
Employers are vicariously liable for theactions of their employees provided thatthe employees were acting in the
course of their employment (sometimeseven if the activity was expresslyforbidden)
Limpus vs London Omnibus Co. (1862)Employer Liable for accident caused bynegligent employee
DUTIES OF EMPLOYEES
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DUTIES OF EMPLOYEES
Employees may also be sued. They have aduty to:
- To carry out duties with reasonable care
- To avoid loss to Employer
(cf Health & Safety at Work etc Act)
NB. Employers not liable for activities that do
not form part of employees employmentservants frolic of his own
Storey v Aston (1869) Employer not liable foraccident caused during unauthorised detour
REASONABLE PRACTICALITY
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REASONABLE PRACTICALITY
Edwards v National Coal Board (1949)Risk must beinsignificant in relation to sacrifice (time, effort & expense):NCB claimed unsuccessfully that it was not reasonablypracticable to shore up all mine roads
Marshal v Gotham & Co (1954) If something is practicable,courts will not lightly hold that it is nor reasonablypracticable
Adsett v K&L Steelfounders & Engineers Ltd (1953) Thestandard of practicality is that of current knowledge
not having sufficient resources is no excuse for inaction
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DEFENCE OF NECESSITY
A defendant may claim that his/her actionsarose from necessity (e.g. to prevent a
more serious accident) ESSO Petroleum Co v Southport
Corporation (1955) A captain of an oil
tanker jettisoned oil in bad weather tosafeguard the crew: ESSO convinced thecourt that this was a necessary act and notnegligence
CONSENT:VOLENTI DEFENCE
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CONSENT: VOLENTI DEFENCE
Volenti non fit injuria: cannot expect redress ifyou consent to an act likely to result in injury orloss
Cutler v United dairies (1933) Cutler failed to
recover damages after being injured trying torestrain a bolting horse: it was held he consentedto the risk
Haynes v Harwood (1935)A policeman was able
to recover damages after being injured restraininga bolting horse: he had a legal duty to protect life& property and was not held to have consentedwillingly to the action
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OCCUPIERS LIABILITY
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ACTS (1957 & 1984)
Duty of reasonable care to lawful visitors(invitees, licensees, contractors & those witha right under law)
Need to ensure premises are reasonablysafe. Dangerous defects must be repairedand warning notices displayed as necessary
Should expect children to be less carefulthan adults
Common Law duty not to cause trespassers
intended harm
TRESPASS: CASE LAW
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TRESPASS: CASE LAW Tichener v British Railways Board (1984)
BRB not liable for injuries to teenage girl hitby a train even though fence was notmaintained (Girl frequently & willingly took
risk) British Railways Board vs Herrington (1972)
BRB liable for injuries to a 6-year old childwho had strayed onto the line
Bird vs Holbrook (1828) Landowner liable forinjuries to a trespasser caused by a springloaded gun (trespasser unaware of risk)
THE WOOLF PROTOCOL
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THE WOOLF PROTOCOL
Lord Woolf (the Lord Chief Justice) drewup a Personal Injury Pre-action Protocolaimed at simplifying & streamlining claim
procedures Claims must proceed to a strict timetable
Defendants must investigate claims &
disclose relevant documents within thetimetable
If the protocol is not complied with, Courts
may impose tough sanctions
CRIMINAL COURTS (E&W)
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( ) All criminal cases are first dealt with by Magistrates Courts.
these can try summary offences and can commit people
accused of indictable offences (& commit people forsentencing) to the Crown Court.
The Crown Court tries Indictable offences. Trial is before aJudge (with a Jury in contested cases. Can also hear appeals
from Magistrates Courts.
The High Court of Justice hears appeals from Magistrates &some appeals from Crown Courts.
The Court of Appeal (Criminal Division) hears appeals fromCrown Courts it can amend or reverse decisions or remit casesto lower courts
The House of Lords is the ultimate court of appeal
HEALTH & SAFETY AT WORK
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ETC ACT 1974 (HSAWA)Section 2: duty to ensure, so far as is reasonably practicable
the health safety & welfare of employees
safe workplace & safe working practices
information, training & supervision
adequate welfare facilities
health & safety policy
safety representatives & committees
Section 3: employers to conduct undertakings so as to ensureso far as is reasonably practicable that persons not in hisemployment are not exposed to risks to their health & safety
HSAWA - (ii)
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HSAWA (ii)
Section 4: duty of those in control of premises to
non-employees
Section 6: duties of manufacturers & suppliers(includes provision of safety information)
Section 7:duty of employees to take reasonablecare for their health & safety and that of othersaffected by their acts/ omissions and to co-operatewith employer
Section 8:no person to intentionally/ recklesslyinterfere with or misuse anything provided for health,safety or welfare
Section 9:no charge to employees for H&S items
HSAWA (iii)
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HSAWA - (iii)
Section 36:where the commission of anoffence is due to the default of another
person - that person shall be guilty of theoffence
Section 37:Directors are responsible (as
well as the body corporate) for offencescommitted with their consent/connivance orattributable to any neglect on their part
HEALTH & SAFETY
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HEALTH & SAFETYREGULATIONS
Made under the Health & Safety at Work etcAct 1974
Often required by European Directives
Consultative Documents issued by Health &Safety Commission
Signed by the Secretary of State
Laid before Parliament Have coming into force (CIF) dates
Most may be cited in breach of statutory
duties actions (but not HSAWA or MHSWR)
REGULATIONS !
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REGULATIONS !Management of H&S at Work * Workplace Health,
Safety & Welfare * Working time * Provision & Use ofWork Equipment * Personal Protective Equipment atWork * Display Screen Equipment * Manual Handling
Operations * Safety Signs & Signals * PressureSystems * Electricity at Work * First Aid at Work *
Control of Substances Hazardous to Health * Controlof Asbestos at Work * Genetic Modification (Contained
Use) Regulations * Dangerous Substances &Explosive Atmospheres * Ionising Radiations *Genetic Modification * Reporting of Accidents,
Incidents & Dangerous Occurrences
MANAGEMENT OF HEALTH &
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SAFETY AT WORK REGULATIONS
Assessment of risks
planning, organisation, control monitoring &review
health surveillance competent H&S personnel
emergency procedures
information & training
co-operation with other employers
employees to follow instructions &reportserious dangers/shortcomings
WORKPLACE HEALTH, SAFETY
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,& WELFARE REGULATIONS
Maintenance,ventilation, heating & lighting
Cleanliness & waste materials
Space
Workstations, floors & traffic routes
Measures to prevent falls or falling objects
Windows, skylights & ventilators
escalators, walkways, doors & gates toilets, washing facilities, drinking water
Facilities for changing, resting & eating
PROVISION & USE OF WORK
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PROVISION & USE OF WORKEQUIPMENT REGULATIONS
Work equipment suitable for use
maintained in good repair
information, instruction & training
machine guarding
precautions against specified hazards
controls, isolation, stability, lighting markings & warnings
mobile work equipment & power presses
CONTROL OF SUBSTANCES
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HAZARDOUS TO HEALTH
REGULATIONS Risk assessment
elimination or control of risk maintenance of equipment
environmental monitoring
health surveillance emergency procedures
information, instruction & training
APPROVED CODES OF
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PRACTICE
ACOPs are prepared by the Health & SafetyCommission
Although they are not laid before Parliament, theyhave a legal status
They set out how Regulations may be compliedwith
You do not have to follow the ACOP but if you donot you may have to prove that you complied with
the Regulations by other means
ENFORCEMENT OF H&S LAW:
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ENFORCEMENT OF H&S LAW:POWERS OF INSPECTORS (HSE
etc) Entry to premises
Involvement of police
Make necessary examinations & investigations
To direct premises are undisturbed
To take photographs, measurements & samples
To order plant to be dismantled
Require witness statements
Inspect documents etc
HSE ENFORCEMENT POLICY
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HSE ENFORCEMENT POLICY
See HSE Enforcement Policy Statement Proportionality:relating enforcement to
how far the duty holder has fallen short oflegal requirements
Targeting: concentrating on the mostserious risks
Consistency: taking a similar approach insimilar circumstances
Transparency: telling duty holders what isexpected of them
NOTICES & PROSECUTION
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NOTICES & PROSECUTION
A Prohibition Notice prohibits an activity (e.g. use of adangerous machine)
An Improvement Notice requires improvements (usually
within a time scale) Organisations can appeal against notices to an Industrial
Tribunal
The HSE names and shames offenders
Enforcing Authorities can prosecute offenders for breaches
of HSAWA or Regulations made under HSAWA
MAX PENALTIES UNDER HSAWA
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MAX PENALTIES UNDER HSAWA
Failing to comply with an Improvement/ ProhibitionNotice:
Lower court 20,000 and/or 6 months in prison
Higher court unlimited fine and/or 2 years in prison Breaches of sections 2-6 of HSAWA
Lower court 20,000; higher court unlimited fine
Breaches of regulations etcLower court 5,000; upper court
unlimited fine
R v ASSOCIATED OCTEL
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A contractor working for AO suffered severe burns
when a lamp broke setting fire to solvent vapours The contractors company was prosecuted under
Section 2 of HSAWA (duty to employees)
AO was convicted under Section 3 of HSAWA(duties to others)
AO appealed on the grounds that the work of thecontractors was not part of AOs undertaking
The appeal went all the way to the House of Lordsbefore finally being dismissed: the work was part of
AOs undertaking and they had a duty to ensure the
H&S of the contractors
CORPORATE
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MANSLAUGHTER
A company cannot have a criminal state of mind
At present, a company can only be convicted ofmanslaughter if the Controlling mind is first proved
guilty
This is normally only possible with very smallcompanies
R v OLL Ltd (1994) following the death of 4 childrenon a canoe trip OLL fined 60K & the managingdirector jailed
Changes in the law are imminent
Legal Requirements
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Health & Safety at Work etc Act 1974
Management of Health & Safety at WorkRegulations 1999
Failure to comply is a criminal act
Employers CANNOT insure against failureto comply
Section 2
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Section 2
Section 2(1) - employers general duty
Duty to ensure so far as is reasonablypracticable, the health, safety and welfare atwork of employees and any others who may beaffected by the undertaking.
Legal Standards
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Legal Standards
Reasonably Practicable or SFARP
Implies a weighing up of the risk against the cost
(in terms of time, money or trouble) of preventingor controlling the risk
Section 2 (cont )
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Section 2 (cont.) Provision of such information, instruction,
training and supervision as is necessary toensure , SFARP, the health and safety at work
of employees and any others who may beaffected.
Section 2 (cont )
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Section 2 (cont.)
Duty of Employers to Employees cont. 2.2a - safe plant and systems of work
2.2b - safe use, handling, storage andtransportation of articles and substances
2.2c - information, instruction, training andadequate supervision
2.2d - safe place of work and a safe means of
access and egress 2.2e - safe working environment and adequate
welfare facilities
Section 7
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Section 7
Duty of Employees at WorkIt shall be the duty of every employee whilst at
work:-
to take reasonable care of their own health andsafety and of any other person who may beaffected by their acts or omissions
to co-operate with their employer so far as isnecessary to enable that employer to meet theirrequirements with regards to any statutoryprovisions
S ti 21
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Section 21
Improvement NoticesIf an inspector is of the opinion that a person:-
is contravening one or more of the relevant
statutory provisions; or has contravened one or more of those statutory
provisions, in circumstances that it is likely thatthe contravention will continue or be repeated,
then he will issue an Improvement Notice.
S ti 22
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Section 22
Prohibition NoticesIf any activity is being, or is about to be, carriedout that could result in serious personal injury,
then an inspector may issue a ProhibitionNotice. This notice will cause the immediatecessation of the activity involved until allmeasures are rectified.
Enforcement
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Enforcement
The HSE can take legal action against anemployer/employee in a criminal court for H&Sfailures:
Unlimited fine and/orCustodial sentence
(Remember - you cannot insure against failure tocomply with H&S legislation)
If guilty = criminal record
British Justice
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British Justice
INNOCENT
until proven
GUILTY
beyond
ALL
REASONABLEDOUBT
Civil Litigation
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Civil Litigation
Provides for compensation to be paid topersons who suffer harm as a result of awork activity.
Can insure - Employers Liability InsuranceBurden of proof is NEGLIGENCE
Proof is on the balance of probabilities
Effectively guilty until you prove yourinnocence
Reportable
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Reportable
Reporting of:
Injuries (accidents & incidents)
Disease
Dangerous Occurrences
(Regulations)
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Why investigate?
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It is a reactive element in monitoringphase of your safety managementsystem: Eliminate the causes and underlying
causes to prevent a recurrence; Identifying safety management lapses by
examining shortfall between what you planto happen and what did happen;
Identify trends and patterns for futureprevention;
Evaluates organisations position in relationto potential breaches of law.
Why investigate?
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Accident Reporting &I i i
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Investigation
Objectives for this section:
to understand:
accident definitionaccident causation
accident costs
accident prevention
accident reporting/notification
accident investigation
Accident Reporting &I i i
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Investigation
Common Uninformed Comments
accidents just happen
we dont have many accidents safety is expensive
the insurance will pay
safety is just common sense
Accident Reporting &I i i
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Investigation
Accident Definitionwhat is an accident?
unplanned & uncontrolled event that led to, orcould have led to:
injury to persons, damage to property/plant/equipment,impairment to the environment or some other loss to thecompany
Accident Reporting &I ti ti
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Investigation
Accident Definition
accident types
minor dangerous occurrence
near miss
plant/equipment damage
minor injury
lost time injury
disablement/fatality
Accident Reporting &I ti ti
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Investigation
Accident Definition
Frank Bird (Accident Triangle)
600 near misses
30 property damage
10 minor injuries
1 serious injury (lost time or fatal)
THE ACCIDENT
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THE ACCIDENT
BASIC TYPES OFACCIDENTS
THE ACCIDENT
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THE ACCIDENT
MINOR ACCIDENTS:
Such as paper cuts to fingers or dropping
a box of materials.
THE ACCIDENT
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CC
More serious accidents that cause injuryor damage to equipment or property:
Such as a forklift dropping a load orsomeone falling off a ladder
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THE ACCIDENTNEAR MISS
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NEAR-MISS
Also know as a Near Hit
An accident that does not quite result in
injury or damage (but could have).
Remember, a near-miss is just as serious
as an accident !
THE ACCIDENT
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ACCIDENTS HAVE TWO THINGS IN
COMMON
THE ACCIDENT
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They all have outcomes from the accident
THE ACCIDENT
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They all have contributory factors thatcause the accident
Accident Reporting &Investigation
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Investigation
Accident Causation
environment
personal fault
unsafe act
unsafe condition
accident
injury/damage
Accident Reporting &Investigation
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Investigation
Accident Causation
causal factors
individual
job
organisation
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Accident Reporting &Investigation
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Investigation
Accident Causation
causal factors
job
task
workload
equipment
controls
proceduresenvironment
Accident Reporting &Investigation
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Investigation
Accident Causation
causal factors
organisation
culture
leadership
resources
work patterns
communications
ACCIDENT CAUSATION MODELS - 1
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ACCIDENT
INVESTIGATE PROCESS AND OUTCOMESTEERED BY INVESTIGATORS PRE-CONCEPTIONSOF CAUSATION
CONCLUDE PRIMARY CAUSE IS EITHER:
UNSAFE ACT, or; UNSAFE CONDITION
DEVISE A RULEFORBIDDINGBEHAVIOUR
DEVISE A TECHNICALSOLUTION
Accident Reporting &Investigation
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Investigation
Accident Causation
Kings Cross Fire (1987) - 31died
discarded cigarette
accumulation of rubbish
poor cleaning regime
wooden escalator
failure of fire fighting equipment
lack of emergency training poor safety culture
Accident Reporting &Investigation
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Investigation
Accident Causation
Herald of Free Enterprise (1987) - 189 died
failure to close bow doors
no checking/reporting system
commercial pressures
internal friction
disease of sloppiness
Accident Reporting &Investigation
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Investigation
Accident Causation
Clapham Junction (1988) - 35 died & 500 injured
signal failure
incorrect maintenance
degradation of working practices
training problems
communication problems
poor supervision excessive working hours
failure to learn lessons
Accident Reporting &Investigation
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Investigation
Accident Causation
Piper Alpha (1988) - 167 died
maintenance error
inexperience
poor maintenance procedures
communications breakdown
permit to work system fault
safety procedures not practised
Accident Reporting &Investigation
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Investigation
Accident Causation
Automotive Supplier (1999) - 1 died
poor safety culture
lack of guarding
lack of training
poor perception of risk
no safe systems of work
no risk assessment programme no effective accident system
no communication
OUTCOMES OF ACCIDENTS
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NEGATIVE ASPECTS
Injury & possible death
Disease Damage to equipment & property
Litigation costs, possible citations
Lost productivity Morale
OUTCOMES OF ACCIDENTS
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POSITIVE ASPECTS
Accident investigation
Prevent recurrence Change to safety programs
Change to procedures
Change to equipment design
The Aim of the Investigation
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The key result should be to prevent arecurrence of the same accident.
Fact finding: What happened?
What was the root cause?
What should be done to prevent recurrence?
The Aim of the InvestigationIS NOT TO:
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IS NOT TO:
Exonerate individuals or management.
Satisfy insurance requirements.
Defend a position for legal argument.
Or, to assign blame.
Accident Reporting &Investigation
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Investigation
Accident Costs
insured costsuninsured costs
Accident Reporting &Investigation
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Investigation
Accident Prevention
reasons
humane
economic
legal
Accident Reporting &Investigation
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Investigation
Accident Prevention
control measures
safety procedures/work instructions
adequate training
effective communications
good housekeeping
guards/safety devices/warning signs
adequate working environment regular safety inspections
risk assessment
Accident Reporting &Investigation
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Investigation
Accident Reporting/Notification
internal report form
HSE RIDDOR report
injury claim requirement
Accident Reporting &Investigation
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Investigation
Accident Investigation
reasons
identify root causes
identify faults
identify corrective/preventative action
prevent recurrence
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THEINVESTIGATION
Objectives
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Recognise the need for an investigation
Investigate the scene of the accident
Interview victims & witnesses
Distinguish fact from fiction
Determine root causes
Compile data and prepare reports
Make recommendations
ACCIDENTS & ILL HEALTHREASONS FOR INVESTIGATION
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REASONS FOR INVESTIGATION
to record what happened RIDDOR legal reporting requirement
compensation claims/insurance to find out what & why it happened
immediate causes (What)
underlying causes (Why)
to prevent recurrence the next incident could be more serious
Traditional approach to accidentinvestigation
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investigation
Safety management has concentrated onaccident investigation as it is a good dealeasier than proactive prevention
Key features: Search for the primary cause, and
Debate whether the primary cause was
and unsafe act or unsafe condition
HEINRICH'S TRIANGLE( )
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300
29
1 MAJOR INJURY
MINOR INJURIES
NON-INJURY INCIDENTS
(1950)
Accident causation
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First accident model was Heinrich (1931).Domino theory
Social environment Fault ofperson
Unsafe Act
Unsafe condition
Accident Injury
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HSE Guidance on accidentinvestigations [HSG 65]
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Need for line managers to take responsibilityfor investigation;
need for adequate training for investigators;
importance of investigating both accidentsand other incidents and near-misses - esp.those with potential for serious injury;
need to deal with immediate consequences atscene by treating, helping and rescuingpersons and making site safe;
contd
investigations [HSG 65]
HSE Guidance on accidentinvestigations [HSG 65] contd
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investigating to appropriate depth, depending on itsseriousness; guidance on investigation process to investigators,
including: structured approach
appropriate use of observation, documents andinterview evidence; use of model to guide collection of evidence and its
assembly for evaluation need to explore immediate and underlying causes
developing specific objectives for implementingfindings
need to record essential data
Attending the accident scene
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OBSERVE
Look at the scene and the surrounding area Take measurements and produce a diagram
Take photographs
INTERVIEW
The injured person and/or witnesses(preferably separately)
At the scene if possible(within 48 hours)
Note down beforehand some key questions to beanswered - CHECKLIST
Ask open-ended questions in a friendly manner
KEEP AN OPEN MIND (be aware of your bias)
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Statements
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Introduce yourself (if necessary)and explainyour role what needs to be done
Invite safety rep or another person they would
like to sit in, but not answer questions If trainee under 18 years, interview with an
adult, preferably a parent
Run through your questions and what theywitnessed and make notes to help structure astatementEach persons summary
A modern approach
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Immediate causes and underlying causes HSG65
Accidents are Multi-causal
Understanding of the complexities ofhuman factors
Understanding of management systems
Promotion of a safety culture
HS(G)65 Appendix 5Immediate causes (what)
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Immediate causes (what)
4 Ps Premises
Plant/Substances
Procedures
People
Premises
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Physical layout Condition of building
Environment (weather)
Tripping & slipping hazards
PLANT/SUBSTANCES
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Machinery guarding Substance in usetoxic, harmful
Mobile plant
Item of work equipment hand tools,chairs
PROCEDURE
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Written system of work/operatingprocedure to be followed
Safety Policy
Work instruction Quality standard
Custom and Practice does not have to
be a document
People
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Human factors State of health (eye sight)
Abilities
Errors skill based (slip or lapse), rulebased, knowledge based or violations
Behaviour pressures, culture
Underlying causesRoot causes (Why)
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( y)
5) Planning
6) Risk Assessment
7) Control(Supervision)
8) Co-operation
9) Communication
10) Competence
11) Monitoring 12) Reviewing
HSG65 APPENDIX 5
IMMEDIATE CAUSE UNDERLYING CAUSE
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PREMISES
PLANT AND
SUBSTANCES
PROCEDURES
PEOPLE
PLANNING
ASSESSING
RISKS
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
ORGANISATION
CONTROL
ORGANISATION
CO-OPERATION
ORGANISATION
COMMUNICATION
ORGANISATION
COMPETENCE
MONITORING
REVIEW
Hazards
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IdealReality
Management
Arrangements
RCS
WorkplacePrecautions
Underlying
Causes
ImmediateCauses
Hazards
Accident
Essential data in investigation reports
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Details of injured person - age, sex,experience and training, etc;
Description of circumstances - place, date,
time and conditions; Details of the event - actions leading directly
to event/ direct injury causes;
Underlying causes;
contd
Essential data in investigation reports
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Details of outcomes: nature of injuries, ill-health, losses;
severity of harm;
immediate management response and its adequacy;
First-aid response;
Potential consequences:
what was the worst that could have happened?
What prevented it from happening? How often could it recur and how many affected?
Accident investigationNotified of accident
S d f
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Scene made safe
Collect facts to answer 5 Qs: What, when, where, who, how?
By: 1. observation 2. documentation 3. interviews
Refer to relevant standards for comparison:[a] legal or good practice, and;[b] safety management plan.
Analyse differences between what happened and what should have happenedto identify causes and underlying SMS lapses
Target report atdecision-makers
Feed into monitoring/review stages of SMS forvalidation/verification comparison
Follow-up to implement necessary changesto SMS plan AND site
Accident Reporting &Investigation - team
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g
Accident Investigation
investigation team
supervisor
safety rep
engineer
manager
safety officer
Accident Reporting &Investigation - objectives
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g j
Accident Investigation
investigation objectives
establish chain of events
identify root causes
identify faults
identify corrective/preventative action
Accident Reporting &Investigation - techniques
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g q
Accident Investigation
investigation techniques
attend promptly
ensure medical attention
leave scene undisturbed
take photographs/sketches
take measurements
take samples gather documentation
interview witnesses
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Accident Reporting &Investigation - report
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Accident Investigation
investigation report
identify team
summarise consequential events identify root causes
describe other weaknesses
identify corrective/preventative action
allocate responsibility & timescale
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Working together
improving safety
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What are you doingto involve your
workforce?
What is workforce involvement?
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Involve the workforce as equal partners Actively seek their views
Value their positive contribution
Enable effective involvement in all areas ofH&S management
Be ready to change things and challengeprevious management practices
Nurture, support and sustain the partnership.
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Do you shape up?
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Are employees involved in long term H&S Are workers involved in writing safe working
procedures?
When accidents are investigated are safety repsfully involved?
Do H&S audits include safety reps as well asmanagers?
Where is all this from?
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HSE booklet HSG217 Involving employeesin health and safety
Aimed at the chemical industry but should
apply to everyone Does it apply to you?
Health and Safety
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Health and Safety
Management
Safety Representatives
Safety Officers
And Safety Committees
Members and Meetings
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All work areasshould berepresented
Members should beinterested,concerned and willing to learnmore about h&s
Willing to meet oncea month and tocommunicate withworkers
Meetings discussworkers concerns
Possible solutions
Approaches tomanagementnegotiations
Ongoing concerns
and progressreports to union
Functions of Committee Conduct regular inspections and
surveys on safety and health
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surveys on safety and health
Respond to workers concerns on OHS
Make reports and recommendationsto improve compliance with law andstandards
Propose policies, work plans, projectsand activities to reduce accidents and
illness
Propose and organise trainingprogrammes for the workforce
Functions of Committee
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Promote and support activities on OHS
Follow up progress of proposals
Report on results achieved, point out
obstacles and problems Investigate, record and report on all
accidents, ill health and near misses
Propose regulations on health andsafety
Organise occupational health services
What makes a committee work?
Have a plan and objectives and actively pursue
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Have a plan and objectives and actively pursue
them with the broadest support possible
Communicate and educate to get that support
Need facilities, time off, info and training
Agendas in advance, proper minutes, decisions
If union reps make coherent proposals in writing:describe the problem, include the facts; suggestimprovements; decide who will do what; timetableand budget.
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PLANNING
Building Partnerships
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POLICY
ORGANISATION
PLANNING
MEASURING
AUDIT &
REVIEW
commitment
agreed goals
leadershiprespect forlegitimateinterests
shared vision
positiveculturechange
openness
transparency
trust
honesty
Partnership
building
blocks
H&S
management
system
HSG65
This is what you need to do
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Involve the workforce as equal partners
Actively seek their views
Value their positive contribution
Enable effective involvement in all areas ofH&S management
Be ready to change things and challenge
previous management practices Nurture, support and sustain the partnership.
If you do that
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We will genuinely be working together
You will be improving H&S
The workers will be healthier and safer
You will be financially healthier and safer
it works !
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For attendingthis course
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