Health and Safety Monitoring and Measuring
A management system only improves when its results are checked. This element covers how incidents are investigated and recorded, the difference between active and reactive monitoring, how audits work, and how management reviews performance and turns the findings into action.
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4.1 Investigating and Reporting Incidents
The levels of investigation
Incidents can reveal failed risk controls, but an investigation must establish the actual causes from evidence. HSG245 uses adverse event as an umbrella term for its investigation guidance. Its older use of "incident" differs from the broader ISO 45001 usage adopted in the current NEBOSH syllabus, which includes events that caused, or could cause, injury or ill health.
- Accident: an event that results in injury or ill health.
- Incident in HSG245 terminology: an event without injury or ill health; the workbook distinguishes:
- near miss: an event that caused no harm but had the potential to cause injury or ill health
- undesired circumstance: a set of conditions with the potential to cause injury or ill health, for example untrained nurses handling heavy patients
HSE guidance HSG245 explains how to decide the level of investigation needed. The table below helps match the level to the event. Always consider the worst potential consequence and not just what actually happened. A fire that injured nobody may still have had the potential to cause major or fatal injuries.
The likelihood of the event happening again and the worst potential consequence together give a risk level, and the risk level gives the level of investigation: minimal, low, medium or high.
- A minimal investigation: the relevant supervisor looks into the circumstances and tries to learn lessons that will prevent a repeat.
- A low investigation: a short investigation by the supervisor or line manager into the immediate, underlying and root causes, to prevent recurrence and learn any general lessons.
- A medium investigation: a more detailed investigation by the supervisor or line manager, the health and safety adviser and employee representatives, looking for immediate, underlying and root causes.
- A high investigation: a team investigation involving supervisors or line managers, health and safety advisers and employee representatives, carried out under the supervision of senior management or directors, again looking for immediate, underlying and root causes.
Basic steps in an incident investigation
The organisation must set up, carry out and maintain a procedure to report, record and investigate incidents. The reasons for reporting and the reasons for investigating are different.
| Reasons for reporting | Reasons for investigating |
|---|---|
| Prevents severe accidents, because safety issues are found and fixed before they become bigger problems | Legal compliance |
| Saves time and resources that would otherwise go on dealing with more serious accidents | Shows where the risk assessment needs to be reviewed |
| Improves the well-being of every worker | Finds underlying OHS deficiencies and other factors that cause or contribute to incidents |
| Protects the organisation against non-compliance with health and safety regulations | Identifies the need for corrective action |
| Lets the organisation track trends and patterns and discover anomalies | Identifies chances for preventive action and better risk controls |
| Improves other OHS measures on site, such as hazard reporting and risk assessment | Identifies chances for continual improvement |
| Builds a strong health and safety culture | Calculates the cost of the accident |
| Helps management see the significant problems and develop better processes and safe procedures | Processes workers' compensation claims |
| Communicates the results (to insurers, legal bodies and others) | |
| Shows the organisation cares, builds employee confidence and improves public relations |
Investigations must be carried out promptly, and their results documented and kept. A thorough investigation is critical to a safety culture. Without one, continual improvement in workplace safety cannot be managed.
Before any investigation begins, first:
- give first aid to anyone injured
- control the hazards to prevent further injury
- secure the scene
Step 1: gather information
Sources of information may include:
- site photographs and video
- the equipment or machines involved
- manufacturers' data sheets for the substances and equipment involved
- the risk assessment for the activity
- training records of the workers involved
- the permit to work for the activity
- written notes
- measurements
- environmental conditions, including air temperature, noise and lighting
- witness interviews
- interviews with the supervisor, co-workers and others
Gather the information as early as possible after the incident.
Step 2: analyse the information
Once the information is gathered, analyse it to find the cause or causes. Often gathering and analysis happen in turns. Starting the analysis may show the need for further interviews.
An incident is usually not a single event but a chain of events, and the sequence must be understood before asking why it happened. The first step in analysis is normally a detailed timeline, which sets events and actions out accurately in time and helps the investigator test possible causal pathways. After that, many models and methods can help analyse, structure and communicate the findings.
The analysis must consider all possible causes. Keep an open mind and take a thorough, systematic and objective look at the evidence.
Tools that can be used to find root causes include the following. They are not meant to be used alone, and a combination works best.
- brainstorming
- checklists
- logic or event trees
- timelines
- sequence diagrams
- causal factor determination
- 5 Whys: use repeated why-questions to explore causes, checking each proposed link against evidence. There need not be exactly five questions or only one causal chain.
- Cause and effect (fishbone) diagrams: chart all the possible causal factors to see where the trouble may have started
The method chosen affects which factors are uncovered, and so the conclusions and recommendations. One important difference is how far a method helps the investigator dig down to underlying or root causes. Other factors to consider are:
- how complex the method is
- how easy it is to use
- how much training it needs
- how widely it is used in the industry
- how well it communicates results
- how mature the method is
There is no general rule for the best method for a given enterprise. In practice an investigator does best by combining several techniques.
Summary notes for Element 4 · Cheat sheet · Glossary. A study aid, not published or endorsed by NEBOSH.