Element element element element element what should be investigated?

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1.3
ELEMENT 1.1
ELEMENT 1.3
ELEMENT 1.2
ELEMENT 1.4
ELEMENT 1.5
ELIMINATION
SUBSTITUTION
ENGINEERING CONTROLS
SIGNAGE/WARNINGS AND/OR 
ADMINISTRATION CONTROLS
PERSONAL PROTECTIVE EQUIPMENT
THOUGHT PROVOKER
Personal protective equipment is at the bottom of the hierarchy of control. Why do you think this is?
The most effective risk controls are those that create a safe or safer place, rather than relying on safe people.
It is also important to remember that any recommendations for additional risk control measures should be based on the 
outcomes of the investigation, eg evidence based.
Organisations must then consider whether similar risks exist elsewhere, where lessons can be learned from, or applied to.
y
In different departments of an organisation where a similar risk exists: the control measures should be considered for all 
departments, to ensure the potential for recurrence is dealt with in the same manner throughout the organisation.
y
Organisations that have premises in different locations where the same or similar hazards exist: the control measures 
implemented in the area under investigation should be implemented throughout the organisation.
y
In different organisations: how do they manage this risk? Sharing best practice through industry forums can help 
organisations learn lessons.
If an organisation has had similar incidents prior to an adverse event, they will need to determine:
y
whether they were investigated thoroughly after the last adverse event; 
y
what additional risk control measures were put into place; and
y
why it has been allowed to happen again, eg why did the existing or additional risk control measures fail.
Action should be taken more promptly in these circumstances.
Organisations who ignore safety failings are not looked kindly upon during any prosecutions or investigations, and this may be 
reflected in the severity of any penalty issued by the state or judge.

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NEBOSH HSE Introduction to Incident Investigation