NEBOSH HSE Introduction
to Incident Investigation
28
1.3
ELEMENT 1.1
ELEMENT 1.3
ELEMENT 1.2
ELEMENT 1.4
ELEMENT 1.5
What should be investigated?
When deciding on what to investigate and the level of investigation, there are several things to consider:
y
the worst possible outcome of the incident;
y
the likelihood of
the incident happening again;
y
the lessons that can be learned and applied throughout
the organisation;
y
whether there has
been a breach of legislation;
y
whether there are any civil liability implications;
y
if there is any uninsured risk(s); and
y
whether the incident could have impacted on neighbours
or members of the public.
As
discussed earlier in this book, some incidents are reportable under local jurisdiction legislation (in Great Britain this is under
RIDDOR).
What does a good investigation look like?
KEY TERMS
Immediate causes
The agent of injury or ill health (the blade, the substance,
the dust, etc).
Underlying causes
Unsafe acts and unsafe conditions (the guard removed, the ventilation switched off, etc).
Root causes
The failure from which all other failings grow (failure to identify training
needs and assess competence, low priority given
to risk assessment, etc).
10
Non-conformance in relation to incidents as detailed in the international standard ISO 45001: “Although there can be
one or more non-conformities
related to an incident, an incident can also occur where there is no non-conformity.”
Incidents can have one or more
immediate causes, eg a worker tripping over a trailing electrical cable and wearing the wrong
footwear, but there will also be one or more underlying causes of why the accident occurred. In
the case of the trailing cable,
underlying causes may relate to why the cable was left trailing there (sometimes known as the ‘unsafe condition’) and why
the worker did not see the cable and then tripped over it (sometimes known as the ‘unsafe act’).
