Accidents can happen even in the best workplaces. Sometimes multiple small failures can lead to an incident or accident.  When they do, you want to know why this happened in order to understand how to prevent it happening again.  The importance of this cannot be overstated, but we must also recognise our innate tendency to blame simple things without looking into the actual root cause(s).

Luckily, HSE have produced some simple guidance to help you through this process, and this is summarised below for your convenience.

HSG245: How to Investigate Workplace Accidents and Incidents Effectively

The Health and Safety Executive (HSE) has long provided guidance to help employers understand what went wrong when an accident or incident occurs at work.

One of the most useful resources is HSG245 – Investigating accidents and incidents, a practical workbook designed to help employers, safety professionals, managers and worker representatives investigate incidents properly and, importantly, learn from them.

The message behind HSG245 is straightforward: an accident investigation should not simply establish what happened. It should establish why it happened and what needs to change to prevent it happening again.

For businesses, this means looking beyond the immediate event and identifying the underlying and root causes that allowed the incident to occur in the first place.

Why is accident investigation important?

• When a workplace accident happens, there can be an understandable tendency to focus on the person involved.
• Perhaps an employee was not following the procedure.
• Perhaps they were not wearing the correct PPE.
• Perhaps they made an error.
• While these things may form part of the investigation, stopping there can mean missing the real causes of the incident.
• HSE guidance emphasises the importance of identifying the underlying causes of human failures and looking at the wider organisational factors that influence how work is actually carried out.
• For example, if an employee bypasses a machine guard, the investigation should not necessarily end with:
• “The employee failed to follow the procedure.”
• A better investigation would ask why.
• Was the guard difficult to use?
• Was production pressure encouraging people to take shortcuts?
• Was the procedure realistic?
• Had the employee been properly trained?
• Was the equipment properly maintained?
• Was there adequate supervision?
• Had the risk assessment considered the way the machine was actually being used?
• Were similar concerns raised previously?

These questions can reveal weaknesses in the safety management system that might otherwise remain hidden.

What is HSG245?

HSG245 is the HSE’s Investigating accidents and incidents workbook.

Although originally published in 2004, the HSE continues to make the guidance available as an important resource for organisations carrying out workplace investigations.

The workbook provides a structured approach covering four key areas:

• Gathering information
• Analysing information
• Identifying risk control measures
• Developing and implementing an action plan

This provides a useful framework for businesses that want their accident investigation process to go beyond simply completing an accident form.

An effective investigation should result in learning and improvement, not just paperwork.

Accident investigation: look beyond the immediate cause

One of the most useful concepts in HSG245 is the distinction between immediate, underlying and root causes.

Immediate causes

These are the things directly associated with the incident.

For example:

• A worker’s hand comes into contact with moving machinery.
• A person falls from a ladder.
• A vehicle strikes a pedestrian.
• A worker is exposed to a hazardous substance.

These are important, but they rarely tell the whole story.

Underlying causes

Underlying causes are the unsafe acts or conditions that contributed to the incident.

These might include:

• Inadequate guarding
• Poor workplace layout
• Inadequate supervision
• Insufficient training
• Poor maintenance
• An unsuitable procedure
• Inadequate risk assessment
• Failure to follow established controls

Root causes

Root causes go deeper.

They are the organisational or management failures that allowed the immediate and underlying causes to exist.

For example:

• Failure to identify training requirements
• Poor allocation of resources
• Inadequate management arrangements
• Weak safety leadership
• Unclear responsibilities
• Poor communication
• Inadequate monitoring
• Failure to learn from previous incidents
• Risk assessments that do not reflect the work actually being carried out

This is where a good accident investigation can deliver significant value.

If the investigation only deals with the immediate cause, the organisation may fix one particular problem without addressing the wider weakness.

If the root cause is identified and properly addressed, the organisation may prevent a whole series of similar incidents.

Don’t automatically blame “human error”

Human error is often identified very quickly following an accident. However, HSE guidance on human factors makes an important point: investigations should consider why the human failure occurred.

People work within systems. The way a task is designed, the equipment provided, the information available, the working environment, workload, supervision, training, communication and management priorities can all influence human performance. For example, telling an employee to “take more care” may do very little if the underlying problem is an unsuitable piece of equipment or a poorly designed process.

Similarly, retraining an employee may not prevent recurrence if the investigation fails to address inadequate supervision or unrealistic production demands.

A strong investigation therefore asks: What made the error possible, likely or difficult to detect? That question can lead to much more effective corrective action.

How should an accident investigation be carried out?

HSG245 provides a useful step-by-step framework.

1. Gather the facts

Start by establishing what actually happened.

This may involve:

• Speaking to witnesses
• Interviewing the people involved
• Taking photographs
• Examining the workplace
• Checking equipment
• Reviewing procedures
• Examining risk assessments
• Reviewing training records
• Checking maintenance records
• Looking at previous incidents or near misses
• Establishing the sequence of events

It is important to gather evidence before assumptions start to influence the investigation. Photographs, physical evidence, documents and witness accounts can all help establish what happened.

2. Establish the sequence of events

Try to reconstruct what happened before, during and immediately after the incident.

A simple timeline can be extremely useful.

Ask: What happened?

Then: What happened immediately before that?

And then: What happened before that?

This process can help investigators identify the chain of events leading to the accident rather than concentrating only on the final action.

3. Identify immediate, underlying and root causes

Once the evidence has been collected, analyse it. Avoid stopping at the first explanation.

For every apparent cause, ask: Why did this happen? Then ask why again.

For example:

• Worker fell from a ladder.
• Why?
  • The ladder moved.
• Why?
  • It was not properly secured.
• Why?
  • The task was being carried out without a suitable access plan.
• Why?
  • The risk assessment did not adequately consider the work at height activity.
• Why?
  • The organisation’s system for reviewing temporary work activities was inadequate.

The exact causes will vary from incident to incident, but the principle is important.  The objective is to understand the chain of failures.

Near misses should not be ignored

• An incident does not need to result in an injury before it becomes worth investigating.
• Near misses can provide valuable information about weaknesses in a safety management system.
• A falling object that narrowly misses someone may reveal the same underlying problem that could eventually result in a serious injury.
• Investigating near misses allows organisations to learn from events before someone gets hurt.
• This is particularly important where a near miss has significant potential consequences.

The HSE’s approach to organisational learning emphasises the importance of using incidents, accidents and near misses as sources of information and acting on the lessons identified. A business that only investigates incidents after someone has been seriously injured is missing an opportunity to intervene much earlier.

What about RIDDOR?

Accident investigation and RIDDOR reporting are two different things, although they can arise from the same incident. RIDDOR – the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations – requires certain work-related deaths, injuries, occupational diseases and dangerous occurrences to be reported to the relevant enforcing authority.

Not every workplace accident is reportable. For example, HSE guidance states that work-related accidents resulting in a worker being incapacitated for more than seven consecutive days are reportable, while certain specified injuries must also be reported. For most deaths, specified injuries, relevant non-worker hospital-treatment cases and dangerous occurrences, notification must be made without delay and the report must be received within 10 days. Over-seven-day injuries must be reported within 15 days.

Importantly, making a RIDDOR report does not replace the need to investigate the incident.

Likewise, an incident that is not RIDDOR reportable may still warrant investigation because it could reveal a significant weakness in your health and safety arrangements.

What should happen after the investigation?

This is where many investigations fall short.

An investigation may identify several recommendations, but unless those recommendations are actually implemented, the organisation has not necessarily learned anything.

Corrective actions should therefore be:

• Specific
• Proportionate
• Assigned to named people
• Given realistic deadlines
• Monitored through to completion
• Checked to confirm that they have actually worked

For example, “remind staff to take care” is unlikely to be a strong corrective action.

A better action might be:

“Review the machine guarding arrangements, amend the risk assessment and safe system of work, provide appropriate training and verify implementation through a management inspection within 30 days.”

The second approach is measurable and addresses the system rather than simply placing responsibility on an individual worker.

Does your investigation process ask the right questions?

A useful workplace accident investigation should consider questions such as:

This approach helps move an investigation away from “Who was at fault?” and towards “What needs to change?”

Workplace accident investigation checklist

Employers should consider reviewing their current arrangements against the following checklist:

The real purpose of an accident investigation

A workplace accident investigation should not be about producing a report that sits in a filing cabinet. The real purpose is to learn from what happened and prevent recurrence. HSG245 remains a valuable reminder that accidents rarely have a single cause.

There may be a sequence of decisions, conditions, omissions and organisational weaknesses that gradually line up to create the incident. Deal with only the final event and the organisation may remain vulnerable. Deal with the underlying and root causes and there is an opportunity to make the workplace genuinely safer.

This also fits closely with the HSE’s wider approach to health and safety management. Effective safety management is not simply about having policies and procedures in place. Organisations need to check whether their arrangements are actually working and use information from incidents and other sources to continually improve.

How Outsource Safety can help

At Outsource Safety, we help organisations develop practical and proportionate health and safety arrangements that work in the real world.

Whether you need support with accident investigation, risk assessments, health and safety audits, policies, training, inspections or ongoing competent person support, our experienced consultants can help you understand where improvements are needed.

Our Safety~net competent person support service provides businesses with ongoing access to professional health and safety advice, helping employers manage their legal responsibilities and identify potential problems before they result in an accident.

If you have recently experienced a workplace accident or near miss, or you are not confident that your current investigation process is identifying the real causes, it may be time to review your arrangements.

The best time to find weaknesses in your safety management system is before they result in a serious accident.

If you would like to discuss your health and safety arrangements or need support with an accident investigation, contact the Outsource Safety team or click here to request a call back.