- HSE inspectors receive extensive classroom training in investigation procedures and techniques over their first few years of service. - The document discusses the six key questions ("six honest serving men") that should be asked in any accident investigation: why, when, where, who, what, and how. - A good investigation aims to find out what happened, prevent future accidents, and report back to the employer. Conducting the investigation without prejudice is important to achieve these goals.

1. Effective Accident Investigation

2. “Effective Accident Investigation”
• HSE Inspectors receive approximately 5
solid weeks of classroom training purely on
investigation procedure and techniques in
their first four or five years of service .
• Today, we have approximately 40 minutes…
• I hope to encourage you to think about
some of the main issues to do with
Investigating.
• Feel free to ask questions or challenge what
I’m saying

3. Effective Accident Investigation
“I keep six honest serving men; they
taught me all I knew; their names are
what and why and when; and how and
where and who.” – Rudyard Kipling:
from “Elephant Child”

4. Effective Accident Investigation
Six honest, serving men.
Ask yourselves these questions ABOUT
your accident investigation: -
• Why?
• When?
• Where?
• Who?
• What?
• How?

5. Generally people are PAID to do accident
investigations in order to achieve three
key objectives
1) Find out what happened
2) Prevent the accident happening again
3) Report back to your employer on …
WHY are YOU doing an Accident
Investigation? – 1st
Honest Man

6. Yes – All “effective” accident investigations will
split the “find-out-what-happened” objective
in to two DISTINCT phases
1. Information gathering/Evidence collection
2. Analysis
The “Report-back-to-your-employer” objective
can affect how you do the information
gathering and the analysis - prejudice!
Is the reason why I’m doing an
Investigation important?

7. • Prejudice will potentially affect your information
gathering and your analysis. This could stop
you from preventing a reoccurrence of the
accident.
• “…as soon as possible in the investigation
procedure determine the root cause of the
accident – this will maximize the efficiency of
the investigation…” – extract from a large
nationwide employer’s investigation policy –
not good!
Prejudice

8. “Find-out-what-happened”
When, Where and Who?
• When should I investigate? –
Mandatory Investigation? Quality of
evidence. ASAP? Stop dangerous
practice.
• Where should I investigate? – Safe
area? Potential Trauma? Preservation
of Evidence?
• Who should investigate? – Training?
Expertise? Prejudice? Experience?

9. “Find-out-what-happened”
When?

10. “Find-out-what-happened”
Where?

11. “Find-out-what-happened”
Who?

12. “Find-out-what-happened” – WHAT?
Structure – 5th
Honest Man
• What am I trying to find out? – Needs a
structured approach!
• For example: HSG65 Appendix 5
• A twelve stage approach to accident
investigation.
• Very thorough
• Might not be appropriate to your
investigation
• Good starting point/Aide Memoir

13. “Find-out-what-happened” – What?
Structure – Fit for purpose?
• HASAW Act 1974 Section 2(1)
• Safe Place of Work
• Safe Plant and Equipment
• Safe Systems of Work:
• Information
• Instruction
• Training
• Supervision

14. “Find-out-what-happened” – WHAT?
Information / Facts / Evidence
• Information is defined as facts about a
situation, person or event
• A Fact is something that is known to have
happened or to exist.
• Evidence is one or more reasons for
believing that something is true or not true
• Admissible evidence… No opinion, No
hearsay, no rumour.

15. • How should I gather information?
• Physical evidence and analysis –
specialist/expert witness
• Documentary evidence – procedure
• Video / CCTV recordings – “video time”
• Measurements, sketches, photographs
– experience
• Verbal evidence – Statements –
training & experience needed (question
sets?)
“Find-out-what-happened” - HOW?
6th
Honest Man

16. “Find-out-what-happened”
Verbal Evidence - Statements
• Who do you take statements from?
• Question sets?
• Witnesses who have spoken to other
witnesses or managers – false memory
syndrome.
• Stress/Duress – quality of evidence
• Fit for purpose

17. “Find-out-what-happened”
Verbal Evidence – Not easy!
.
• “…you did have your headlights on when
you hit him, didn’t you?...”
• Leading questions. False Memory Syndrome
• Any better suggestions?
• Funnelling

18. • TED - “Tell me…Explain…Describe”
• “Tell me about your journey to work…”
• Open Questions – 6 Honest Men
• “when do you use your headlights?”
• Closed Questions – yes/no
• “So on that morning, because it was
raining you had your headlights on?”
“Find-out-what-happened”
Verbal Statements - Funnelling

19. “Find-out-what-happened”
Analysis - Schedule of Facts
• What information/facts/evidence do you
have? Where did it come from and how
reliable is it?
• “Miss Scarlet was in the library” –
Confirmed by Professor Plum and
Colonel Mustard.
• Have you pursued all reasonable lines
of enquiry?

20. “Find-out-what-happened”
ANALYSIS – ECFA, Fault Tree, etc
• What are “all reasonable lines of enquiry”
• Event and Causal Factor Analysis: - (Events,
Conditions, Queries)
• e.g. Finger Amputation in a vertical spindle
moulder.
• Event – Finger comes in to contact with
moving blade.
• What conditions are necessary for this to
occur?

21. “Stop it happening again”
• If your “find-out-what-happened” objective has
been effectively met then you will probably
already have instigated measures to stop the
accident happening again.
• It is still important to stop at this point and ask
yourself the question “could this happen
again?”
• There can be some of this involved in the
report

22. “Stop it happening again”
Remedial Actions – Report Part 3
• Accident reports should be in at least
two parts (see next slide).
• YOUR accident reports may well be in
three parts (or more)
• Part 3 – Remedial Actions to prevent a
reoccurrence of this accident and
address any underlying failings in
hardware or software.
• Ownership, Timescales, Circulation

23. “Report-to-your-employer”
Report – Part 1
• Factual - Present the evidence that you
have collected – no conclusions, no
opinion. E.g. “…the guard was not in
place at the time of the accident…”

24. • Analysis – Present reasoned arguments,
with justification, for what you believe
happened.
• E.g. “The machine was properly
guarded until the injured person removed
the front guard to clear a blockage…
three witnesses remember seeing the IP
taking the guard off on that morning…”
“Report-to-your-employer”
Report – Part 2

25. “Report-to-your-employer”
Feedback and Critique
• It is important that your reports and
indeed your investigations are reviewed
by somebody not directly involved with
the investigation.
• Investigation technique is something that
is learnt over a long period of time, there
will always be things that you could have
done better

26. Effective Accident Investigation
Fit for Purpose
• You had (hopefully) three objectives in
doing this investigation.
• You should have set yourself three
targets at the beginning.
• Have you achieved those targets?
• Are there any remaining lines of
inquiry?

27. Any Questions?