2. IOSH publishes a two-tier
range of free technical
guidance. Our guidance
literature is designed to
support and inform members
and motivate and influence
health and safety stakeholders.
Direct info
Brief, focused information on health
and safety topics, typically operation-
or sector-specific.
Direction
Strategic corporate guidance on health
and safety issues.
Revised February 2011
3. Contents
Foreword 02
Glossary 03
1 Introduction 04
2 Why do you need internal investigations? 05
3 Preparing and planning your response to hazardous events 05
4 Initial response 06
4.1 Accidents and dangerous occurrences 06
4.2 Occupational ill health and exposure to serious health hazards 07
5 Internal investigations 09
5.1 Investigation team and remit 09
5.2 Roles and relationship 09
5.3 The investigation 10
5.4 Information gathered by external investigators 10
5.5 Investigation and analysis techniques 11
6 Competent investigators 12
7 How to avoid common failings in investigations 12
8 Good practice in investigation reporting 13
9 References 14
10 More information 15
Appendices
A Some relevant UK legislation 16
B Legal privilege 18
C Competence checklist 18
D Hazardous event investigation checklist 20
4. Foreword
When someone loses Thankfully, for most employers, Steve Watts MSc DPM D.Crim (Cantab)
their life in a serious workers and health and safety advisers, FCIM
work-related incident, work-related deaths are rare. But Assistant Chief Constable
organisations can be in preparation and co-operation are key Hampshire Constabulary
a state of shock and to successful investigations and
disbelief. Invariably, where a death knowing who does what and when
occurs in the workplace or as part of a can be invaluable. The important issue
work-related incident, the police – on here is finding out the truth of what
behalf of the coroner – will be involved happened.
as part of their duty to investigate
unexpected death. On a few occasions, This guide tackles a difficult subject
this investigation may need to be more well and is important to law
extensive if questions of culpability enforcement investigators, managers
arise. All those involved at the initial and internal investigators alike.
stages of an incident must be aware of
the need to preserve and gather
information and keep everyone safe.
This will allow others to make well-
founded decisions as to what led to
the worker’s death.
The death or serious lessons are learned for the future. Fatal Peter Brown
injury/illness of a accident investigations are always very Head of Health and Work Division
colleague is a cause of serious, may involve various Health and Safety Executive
sadness and regret and enforcement authorities, and can also
may also raise concerns be lengthy, inevitably raising fears and
among employees about their own uncertainties within organisations. By
health and safety at work. Prevention clearly explaining some of the key
and protection are obviously key, but issues and agencies involved, this guide
where this hasn’t happened, and will help internal investigators to
someone has been seriously harmed or understand what is likely to happen
killed, it’s essential that a thorough and what their role in the process is.
investigation takes place and that
02
5. Glossary
Body mapping
An information gathering technique that uses a chart with large outline drawings of both front and back views of a
body. Groups of workers who do similar tasks are asked to mark on the chart any parts of their body that are affected
by their work. Colour-coding is often used, for example red for aches and pains, blue for cuts and bruises, green for
illness. The data are used to identify if there are any trends or problem areas associated with particular tasks.
Dangerous occurrence
An undesired event that causes significant damage to plant, premises, equipment or the environment. Dangerous
occurrences don’t harm people, but they have the potential to. (The term includes, but is not limited to, items listed
under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995 (RIDDOR),
www.hse.gov.uk/riddor/index.htm.)
Hazardous event
A generic term for an undesired event that causes or has the potential to cause harm or damage, such as serious
occupational accidents, near misses, cases of ill health and dangerous occurrences. Hazardous events include fatal, major
and lost-time injuries, exposure to health hazards, occupational diseases, fires, explosions, accidental releases or
exposures, structural collapses and near misses.
Near miss
An undesired event that doesn’t lead to death, serious harm to people or damage, but has the potential to.
Serious occupational accident
An undesired event leading to death or reportable cases of ill health and injury (see Reporting of Injuries, Diseases and
Dangerous Occurrences Regulations 1995 (RIDDOR), www.hse.gov.uk/riddor/index.htm).
Traumatic incident
A critical, undesired, work-related event that causes psychological distress. Indications of the distress may include
‘flashbacks’ (‘re-experiencing’ the event) or avoiding stimuli associated with the event. Traumatic
incidents involve experiencing or witnessing catastrophic damage, severe injuries, dead bodies or body parts, the death
of colleagues, road traffic accidents, verbal or physical assault, armed raids and hostage taking.
03
6. 1 Introduction
This guide aims to help organisations The guide is aimed particularly at Offered in good faith, this guide isn’t
respond to ‘hazardous events’, such as employers and health and safety intended as a substitute for professional
accidents, cases of ill health, practitioners. It’s not intended as a legal advice, which duty holders should
work-related violence and ‘dangerous practical guide on how to investigate – obtain from a competent legal adviser,
occurrences’. We’ve tailored the advice we refer to other publications that can and we therefore can’t accept liability
to cover fatalities, exposure to offer more detailed advice on this. for its use.
life-threatening health hazards and
high incidence rates of chronic ill We’ve based our advice on current
health problems. Apart from sections arrangements and regulatory practices
5.2 and 5.4, the advice also applies to in England and Wales, although there
less serious events, especially those are some important legal differences in
with the potential for high loss. Scotland and Northern Ireland. While
the objectives and processes of internal
We outline good practice when a investigation may be similar in other
serious event happens, and give countries, the legal system and roles of
information on: the police and labour inspectorates may
- why you should hold internal well be different – so be aware of the
investigations possible differences while reading this
- preparation and planning guide.
- the initial response
- internal investigations: roles, Throughout, we’ve used the term
inter-relationships, information ‘internal investigator’ to mean in-house
gathering and techniques investigators or consultants used by an
- how to make sure investigators are employer to investigate serious
competent incidents on the employer’s behalf. We
- how to avoid common failings in use ‘external investigator’ to mean only
investigations investigators acting on behalf of the
- good practice in investigation police or regulatory authority, for
reporting. example a government inspectorate.
We don’t cover the role of insurers,
although they are also ‘external’ and
often investigate serious events.
04
7. 2 Why do you need internal investigations?
Serious hazardous events, or those that proper controls are in place to Under ‘monitoring’, the approved code
with the potential for a serious prevent similar events. You may also of practice for regulation 5 specifically
outcome, can indicate failures in your want to produce an investigation points out that employers should
organisation’s risk control system and report as a legal defence, and this may adequately investigate incidents and
need to be investigated. It’s important be covered by ‘legal privilege’. (This accidents. There’s also an explicit legal
to understand why the risk assessment issue is not covered in the sections that duty to investigate work-related
and control measures didn’t prevent follow, although the term ‘legal hazardous events where organisations
the event and what needs to be done privilege’ is briefly outlined in Appendix operate under ‘permissioning regimes’,
to make sure it doesn’t happen again. B, page 18). such as British safety case legislation
Investigations also give you the chance applying to major hazard industries
to examine how well your There are also legal drivers for (except offshore). Additionally, British
organisation’s emergency response investigation. Arguably, there’s an law gives a right to investigate to
system worked, so that you can learn implicit duty in Britain under the Health enforcers and union-appointed safety
lessons for improvement. and Safety at Work etc Act 1974 for representatives. There’s also legislation
employers to investigate work-related covering gathering and disclosing
Serious events naturally cause concern hazardous events to prevent them criminal evidence (see Appendix A, page
and anxiety throughout an happening again and to protect the 16).
organisation. A thorough and health and safety of employees and
effectively communicated investigation others. This implicit duty to investigate is To get the maximum business benefit
will help everyone understand exactly also contained in regulation 3 of the for your organisation in terms of
what went wrong and what’s been Management of Health and Safety at minimising future losses, an
done, or needs to be done, to protect Work Regulations 1999,1 which requires investigation should take account of the
people in the future. Shareholders, a review of risk assessments if there are realistic worst consequences of the
investors, clients, insurers and other changes, for example an accident. event, not just what actually happened.
stakeholders will also want assurance
3 Preparing and planning your
response to hazardous events
When there’s a serious hazardous specific posts. It’s vital to make sure Your emergency plans should include
event, your management team will be you have an investigator who’s clear arrangements for immediately
expected to act quickly and decisively competent and has access to adequate alerting the emergency services, senior
in a situation that may be entirely new resources (see section 6, page 12). people in the organisation – for
to them. It’s therefore helpful to devise There’s information on preparing for example, a director or manager
and test a set of ‘emergency and planning to manage occupational responsible for health and safety – and
preparedness’ plans to cover the hazardous events in BS 180042 and in the person in charge of the site or work
various possible types of serious event, guidance prepared for the railway affected. In practice, more than one
such as death, serious damage, injury industry3,4 – this may also be useful in employer may be involved, and it’s
and ill health. Your emergency other sectors. usually the employer in control of the
planning should include appointing an premises who should take the lead in
investigator (or investigation team) – the internal investigation, unless you
either specific people or those in agree otherwise by contract.
05
8. 4 Initial response
This section covers the first actions you authority gives its permission. for and make sure the scene stays
need to carry out when responding to Usually, an inspector will visit the secure.
serious accidents and dangerous scene before letting you start to
occurrences (section 4.1), and cases of clear up. In Britain, where there’s The person you choose may be the
actual or potential occupational ill been a fatal accident, the police will same person who’ll later lead the
health (section 4.2). Where give the all-clear; in cases where internal investigation (‘the
appropriate, they’re the same as the there are no deaths, this will be investigator’), but ‘incident responder’
actions that the first police officer must done by the relevant regulatory and investigator are different roles and
take when they attend the scene of a authority. As long as you don’t can be carried out by different people.
workplace death – these actions are disturb the scenes and evidence, To retain independence and objectivity,
listed in the ‘Investigators guide’.5 As and you don’t compromise the it’s often best to select a competent
well as incident-specific actions, you privacy of people who’ve been investigator from somewhere in the
also need to decide whether there’s a injured, you can take photos, video organisation that has had no direct
risk of a similar occurrence elsewhere footage or sketches involvement in what’s happened.
in the organisation or beyond, and to - make sure key people in the
alert those concerned. organisation are told, such as senior The lead internal investigator will
managers, health and safety usually be an experienced health and
4.1 Accidents and dangerous advisers, workers’ representatives or safety practitioner or a senior manager
occurrences communications department with access to competent advice. If
If there’s a serious accident or - begin a written record of events at there isn’t someone at this level, you
dangerous occurrence, your first the scenes, including a list of should identify another suitable person
priority, as the employer, is to visitors – say, a local manager supported by
implement any emergency plan you - identify witnesses, including people: health and safety adviser – who can
have, including: - involved in or present at the take charge and lead the initial event
- identify the location and extent of time of the event management (securing the scene,
the incident scenes - who may have seen, heard, preserving evidence, recording
- identify any remaining hazards, smelt or felt something information) until the designated
assess the risks and make the relevant investigator can take over.
scenes safe - who have knowledge of the
- provide first aid if needed and call event or circumstances The people and equipment involved in
the emergency services, including - who can confirm the actions the hazardous event may be the
the police and the regulator (in of others or the data that’s responsibility of several different
Britain, call the Incident Contact been gathered employers, and they all may have a
Centre on 0845 300 9923; in - agree with the police (who normally procedure for dealing with and
Northern Ireland, follow the advice take the lead on behalf of all the investigating this sort of event. As each
in www.hseni.gov.uk/riddor- emergency services) – or, where employer will have specific interests
2.pdf) they’re not involved, the regulator – and concerns, joint ‘internal
- secure the scenes – you can do this how you’ll handle communications investigation’ is unlikely, although it
by taping or fencing off the area or with your workforce, relatives of can save time and duplication if they
even posting sentries. You should the dead or injured, and the media can agree to share information (see
also identify, preserve and secure - in co-operation with the emergency section 5, page 09).
any other sites (secondary scenes) services, make arrangements for
or evidence that are separate from supporting anyone who’s been The police and the regulatory authority
the main scene but may be relevant affected by the incident (see page (in Britain, usually the Health and Safety
to the investigation, such as control 08, ‘Support for employees after a Executive (HSE) or local authority) will
rooms, site logs, CCTV footage and traumatic incident’). attend the scene of a fatal accident and
software records. If someone has may visit the scene of other serious
been killed, you need to know Your next priority is to authorise hazardous events. Either the police or
where the body is. If a body has someone to look after your interests at the regulatory authority will take the
been moved, you need to secure its the scene. For serious hazardous lead in a criminal investigation (what’s
current location events, this person’s primary role at this known as ‘taking primacy’) – referred to
- prevent disturbance to the accident stage will be to work with the as the ‘external investigator’ in this
scenes, except to avoid more injury emergency services and regulatory guide.
or damage, until the regulatory authority, provide any support they ask
06
9. If there’s been a work-related death, (which gives a description and analysis 4.2 Occupational ill health and
the first police officer to arrive will take of physical evidence from the site). exposure to serious health hazards
initial responsibility and control of the Working together will also help the People can become ill as a result of
scene. However, the police may pass gathering of other information, for their work some time after the
this responsibility onto the regulatory example witness statements and exposure or event that caused the
authority at an early stage. Sometimes, documents. illness. The delay is called the ‘latent
the police and the regulatory authority period’. The length of the latent period
will carry out a joint investigation. You shouldn’t give out any information depends on the illness and its cause,
Work-related deaths: a protocol for about the investigation to third parties the amount and length of exposure,
liaison8 gives details of the without the formal permission of the and the victim’s individual susceptibility.
arrangements that exist between the external investigator. The media may
police and regulatory authorities in expect briefings and updates, so the If the latent period is long, it’s unlikely
England and Wales, and in Scotland. investigating parties should agree a that you’ll have to act as quickly as you
There’s also a circular aimed at HSE and strategy for releasing information. would for an accident. In general,
local authority inspectors, which covers There’s detailed guidance on media you’ll need to:
liaison arrangements and guidance management after occupational - implement an emergency plan,
relating to potential manslaughter and accidents in the Railway Group including anticipating interest from
homicide cases.9 Standards prepared for the rail the media, employees and the
industry3,4 – the advice may also be public if the illness is potentially
As soon as the initial response is helpful for other occupational accidents widespread, for example food
complete, the internal lead investigator where there’s likely to be media interest. poisoning or cancer
should: - preserve relevant ‘scenes’ and
- take control of the internal If the appropriate authority intends to evidence, for example dust
investigation prosecute, they should tell the duty extraction equipment, documented
- set up a link with the police and/or holders concerned as soon as they have risk assessments, health records
the regulatory authority to avoid enough evidence to support their - authorise someone to take charge
impeding any criminal investigation decision. In these circumstances, the of the internal investigation.
– remember that the external rules of the Police and Criminal
investigation takes precedence over Evidence Act 1984 (PACE) will apply in Also, if the illness or condition is legally
internal inquiries. When the police England and Wales. Northern Ireland is reportable, tell the regulatory authority.
are involved, the key contact is the covered by the Police and Criminal
senior investigating officer (SIO). It’s Evidence (Northern Ireland) Order 1989,
important to make contact with the and Scotland by the Criminal Procedure
SIO early on and maintain good (Scotland) Act 1995.
communications throughout
- plan and outline to relevant The external investigators will decide
employees how the internal when the scene(s) of the accident can
investigation will be carried out, be released. At this point, the lead
noting that the timing may depend internal investigator should take
on what the external investigation responsibility for returning the scene to
requires. the site’s usual management. This can
only happen when the investigators are
The internal investigation may then satisfied that they’ve gathered all the
continue alongside the external inquiry. evidence relating to the accident and
In section 5, we give guidance on the that the site is safe to use. If there’s
potentially complex area of liaison been significant damage, it may be
between the two. necessary to appoint a ‘recovery team’
to oversee repairs and tests before work
The internal investigator should aim to can start again in the affected area.
work with the external investigators and
find out how much information they
can share with each other. For
example, everyone may benefit from
access to the same forensic report
07
10. If you’re dealing with a case of acute - securing the scene(s) investigated even if no-one has
occupational ill health, such as after - agreeing how you’ll communicate reported any symptoms or made a
exposure to asthmagens, allergens with your workforce, relatives of complaint. It’s also important to
and toxic or biological agents,* you’ll the sick, and the media. remember that fears that people have
need to take emergency action that’s been exposed to a serious health
similar to what you’d do for an The investigation should then hazard, and any resulting media
accident. In other words, you need to continue as we describe in section 5 attention, need careful management,
put in place onsite and offsite (page 09). reassurance and clear communication.
emergency plans, which normally If you identify possible cases of
include: You should also investigate events occupational ill health by looking at
- assessing the risk and making the where there’s a significant risk from sickness absence trends or other
scene safe, including evacuation if physical, chemical or biological health indicators – such as the results of
necessary hazards, such as exposure to ‘body mapping’ (see ‘Glossary’, page
- making sure that first aid has been radiation, excessive noise or vibration, 03) and biological monitoring – you
given where needed asbestos fibres or pathogens. This should investigate these too.
- contacting the emergency services kind of exposure should be
and working with them
Support for employees after
a traumatic incident
You should provide practical support to employees on symptoms of PTSD and where to get support in the
immediately after an incident. Things they might need longer term, but you need to consider how best to pass
help with include: this advice on. Victims and witnesses of accidents may not
- contacting their families be able to take in extra information immediately after the
- dealing with the police and investigators event, so it may be better to give this kind of help at a
- preparing witness statements follow-up session.
- accident reporting and other paperwork.
In the longer term, you may want to offer evidence-based
It’s also important for the manager to show empathy,6 therapy to someone who’s deeply affected, but this isn’t
and get advice about the normal range of emotional appropriate as an immediate response. For anyone still
responses to traumatic events. In Britain, guidance for experiencing serious symptoms one month after the
health professionals from the National Institute for accident, NICE recommends ‘trauma-focused’
Health and Clinical Excellence (NICE) on post-traumatic psychological treatment.7 Remember – many people not
stress disorder (PTSD) recommends ‘watchful waiting’ in directly involved in a traumatic incident can be affected
cases with mild symptoms that have lasted fewer than and need support, including investigators. Also, legal cases
four weeks.7 The symptoms often disappear by can take years and people can have the threat of
themselves, and the benefits of intervening in the early prosecution hanging over them for a long time.
stages are unclear. It can be helpful to give information
* In certain countries, some infectious diseases have to be notified to the authorities (for the UK, see www.hpa.org.uk)
08
11. 5 Internal investigations
This section is about in-house but still have a good grasp of the work their memory being corrupted by
investigations. It doesn’t cover basic being done and the usual controls for the passage of time or by discussing
investigation skills – there’s plenty of the relevant hazards. This can be difficult events with their colleagues
information on this available in smaller organisations, but it’s essential - physical and psychological
elsewhere (see section 5.5). Nor does to make sure investigators are trauma – you’ll need advice from
it cover in detail what external competent, and this includes considering doctors about when you can
investigators may do. You can get how independent they are (see section interview people who’ve suffered
guidance from the HSE’s website10 on 6, page 12). serious injury, illness or
external investigations in Britain, and psychological harm as a result of
on the HSE’s investigation procedure 5.2 Roles and relationships the event. Waiting for them to
for major incidents.11 Different bodies investigate accidents recover may delay your
and cases of ill health for different investigation. When you do
5.1 Investigation team and remit purposes – examples include the interview them, keep your questions
Internal investigations into serious employer, the police, the regulatory to the facts and avoid asking them
hazardous events will normally need authority and the employer’s insurer. All about their emotional responses
the skills and time resources of more investigating bodies should have the - survivor guilt – a common reaction
than one person, so a team approach same long-term objective of making sure where people experience
is usual. In the early stages, when you the events don’t happen again. psychological trauma is a strong
still don’t understand the root causes Nevertheless, as there are different feeling of guilt at surviving or
or sometimes even the immediate shorter term reasons for investigating escaping when others haven’t.
causes, it may not be clear exactly (such as law enforcement, liability Recognising this will help you direct
what resources you need. At this mitigation or risk management), people your investigation
stage, it may be enough to appoint an may be reluctant to share information. - contractual issues – there may be
experienced line manager as the team commercial implications which make
leader and an experienced health and Other people and groups will also be someone reluctant to accept (or
safety professional to advise him or interested in the progress and results of imply that they accept) liability
her (see section 6, page 12 for more the investigations, including injured or ill - insurance issues – normally some of
details about team resources and staff and their families, other employees, the costs resulting from work-related
skills). health and safety representatives, trade death, illness or serious damage are
unions, clients, suppliers or contractors, covered by insurance. Generally, a
We recommend that you give your and legal and medical advisers. As a condition of insurance policies is that
internal investigators a written remit result, various issues can affect the policy holder shouldn’t admit
specifying: information gathering and sharing, liability, and this requirement is often
- the purpose of the investigation including: interpreted as an instruction to
- who they should send their initial - self-recrimination – people may volunteer as little information as
report to feel, rightly or wrongly, that they possible
- a timescale for producing their could have done more to prevent - involvement of law enforcers –
report. the event. If people are reluctant to most people caught up in work-
share these feelings with the related deaths and other serious
At least at the start of their inquiry, investigators, it may be difficult to events have little previous experience
you shouldn’t expect your get hold of important information of dealing with the police or other
investigators to do their normal jobs about their actions or knowledge enforcers. They may be unsure of
as well. - self-rationalisation – over time, their rights and responsibilities, and
people may justify to themselves may be particularly worried about
A key role for managers and supervisors what they did or didn’t do, and how they could be implicated in any
is to prevent loss of control and/or minor ‘alter’ their memories so that they ‘criminal act’ which may have been
losses escalating into serious ones – so no longer accurately recall what committed. Even if they’re not
the root causes of serious hazardous happened. This subconscious directly involved, they may be
events are likely to include areas of ‘forgetting’ of important facts is a concerned about being asked to give
management and supervisory deficiency. primary reason for interviewing evidence in court. As a result, they
That’s why the people who lead the witnesses as soon as possible after may be reluctant to volunteer
internal investigation should be the event. Interviewing people information
independent of local line management, without delay also helps prevent
09
12. - legal issues – there may be legal 1 collect information 5.4 Information gathered by
restrictions on the evidence that 2 analyse information external investigators
external investigators are allowed to 3 report and make recommendations When there’s an external investigation
share with you for controlling risk in future. in the UK, you should co-operate with
- production and business issues – the health and safety regulatory
you’ll want to identify the causes of If investigators identify gaps in the authority to avoid committing an
the event and take action to prevent coverage of their investigation, they’ll offence. It’s also good practice to
it happening again. But management need to repeat stages 1 and 2. And if co-operate with the police to establish
will also want to minimise disruption they fail to carry out any stage of the what happened. They may ask you to
to their business, limit damage – investigation fully, they’ll get incomplete provide information about the likely
including loss of reputation if any results and may lose an opportunity to locations of key evidence and witnesses,
management failings are openly prevent the event happening again. It’s but not to interview witnesses or collect
reported – and restore normal important for investigators to make sure any evidence – including at secondary
operations as soon as possible. They that: scenes – until they’ve finished and told
may be reluctant to disclose - the investigation is objective – it you that you can. External investigators
information if it reflects badly on should have the clear aim of from health and safety regulatory
their organisation identifying the immediate and root authorities in the UK can require you
- employment issues – employees causes of the event (why the event and other witnesses to answer
may be reluctant to pass on happened, not just what happened questions at the scene of an
information because they fear that and where) investigation and have a range of other
they, or their workmates, will be - the workforce and any relevant relevant powers to preserve and take
‘blamed’, and that they could be witnesses, including clients, possession of evidence.* The powers of
disciplined or lose their jobs. contractors or suppliers, are involved the police are more limited, unless they
in the investigation and told about exercise their powers of arrest or obtain
Finding ways to help reluctant people relevant findings a warrant. However, if an offence is
give evidence and help is a key skill for a - the recommendations they make as a suspected, the police or health and
competent investigator (see section 6, result of their investigation are safety authorities throughout the UK
page 12). ‘SMARTT’ – specific, measurable, can ask you and anyone else suspected
agreed, realistic, time-bound and of being involved in the offence to
Investigations by different groups may tracked. Normally, line management, attend an interview under caution.
progress at the same time or at different rather than the investigator, decides
times (insurers’ investigations frequently some of these details (see section 7, At times, information may be shared
occur later), but where the police or page 12) and agreed by all parties. However,
other enforcers are involved, their - they review all relevant risk external investigators are unlikely to give
investigations must take precedence. In assessments – if they don’t do this, you information they’ve collected if they
the case of occupational ill health, the they’ll seriously undermine the value plan to use it in a criminal prosecution.
‘event’ may actually be a longer term of the investigation Once a summons is issued, or the
series of events. It may have happened - you publicise the results of the authority decides not to prosecute, this
some considerable time ago or still be investigation, so that the lessons can information will be given, as
going on. be learned as widely as possible – as appropriate, to enquirers if they ask for
well as giving the results to those it.
5.3 The investigation working in the area directly affected,
All investigators will aim to identify the give them to other sites doing similar Where the police or health and safety
human factors and organisational work, and perhaps your trade regulatory authority interview witnesses
failures (‘root causes’) that allowed the association. The UK offshore oil and under PACE, the content of these
incident to happen. The investigation gas industry has an Incident Alerts interviews and statements is
should be a three-stage process: Database to share this kind of
information.12
* Co-operating with the health and safety regulatory authority is covered by section 20 of the Health and Safety at Work etc Act 1974 (or
article 22 of the Health and Safety at Work (NI) Order 1978). The common law offences of obstructing the police and perverting the course
of justice may also be relevant.
10
13. confidential. It’s unlikely that internal These can include deaths: known as ‘events and causal factors
investigators will be allowed to be - caused by violence or accidents analysis’17) and fault tree analysis.18 See
present at these interviews. You’ll be - in prison or police custody section 10 (page 15) for more sources
expected to help identify internal - resulting from industrial diseases, of information on accident
witnesses to the external investigators, such as asbestosis investigation.
and to arrange times for interviews. - during an operation or under
anaesthetic Our Continuing Professional
In Scotland, where reports are - caused by a medical condition not Development courses use the following
submitted, statements are the property previously recognised or treated by ‘basic risk factors’ (potential areas of
of the Procurator Fiscal. Witnesses in a doctor. organisational or management failure,
England and Wales may ask for a copy derived by Groeneweg19) as a starting
of their statements and the external If there are questions surrounding the point for systematically investigating a
investigators will consider the request. cause of death, the coroner may hazardous event. We’ve included an
arrange for a post-mortem. If this example of each failure:
Whether they agree to it depends on a shows that the death wasn’t due to - design, for example failing to apply
number of factors – if they think that natural causes, the coroner will hold an ergonomic principles
the investigation may be compromised inquest. The inquest is an inquiry to find - tools and equipment, for example
by releasing a statement, they can out who has died, how, when and poor quality or condition
refuse. Witnesses can ask to be where they died, together with - maintenance, for example
accompanied at voluntary interviews by information needed by the registrar of inadequate or reactive only
someone of their choice, and the deaths, so that the death can be - housekeeping, for example poor
investigating authority can’t refuse this registered. The purpose of the inquest is standards leading to obstructions or
without good reason. However, the not to attribute blame. There are trip hazards
investigators will consider whether the different arrangements in Scotland, - error-enforcing conditions, for
chosen person may influence the where the role of the coroner is example factors leading to stress or
witness or cause a conflict of interest. performed by the Procurator Fiscal, who distraction
Where witnesses are legally required to may ask for a ‘fatal accident inquiry’.13 - procedures, for example impractical,
give a statement, they have a right to See pages 15 and 17 for links to more not known or not followed
have someone with them. information on the role of coroners. - training, for example not enough for
the task or role
External investigators must give 5.5 Investigation and analysis - communication, for example
receipts for anything they take away techniques inadequate at any level in the
during their investigations (police in There are several hazardous event organisation
Scotland don’t have to give receipts, investigation and analysis techniques. - incompatible goals, for example
but may be willing to). If the These range from straightforward output targets given priority over
authorities take something away, approaches – such as the HSE’s health and safety
always ask for a receipt and keep it guidance in HSG245, Investigating - organisation, for example poor
safe. Make copies of any documents accidents and incidents14 – to complex policies, arrangements or
that you hand over to investigators, ‘logic tree’ systems, which are often management
and where possible keep samples of more useful for serious events. There’s - defences, for example inadequate
any material the external investigators no universally applicable method. alarms or protective equipment.
gather, in case there’s a dispute. Investigators should have a working
knowledge of the available techniques The final choice of which technique to
External investigators can ask for a and choose one that’s appropriate to use lies with the lead investigator – the
copy of the internal investigation the organisation and event. Our chosen technique should be systematic,
report (see Appendix B, page 18). publication Health and safety: risk structured, and appropriate for the
management (chapters 6 and 20)15 event. The same technique is unlikely to
In England and Wales, coroners may be contains a good practical summary of be right in all cases.
involved in investigating work-related the techniques and their attributes,
deaths. They are independent judicial and there’s more detail in Root causes It’s important that you give the
officers, responsible for enquiring into analysis: literature review.16 You can investigation team enough resources,
the medical causes of deaths that are also get free downloads on specific including time, to complete all three
sudden and unexpected, unnatural, techniques, including events and stages of the investigation successfully.
violent or suspicious. conditional factors analysis (formerly
11
14. 6 Competent investigators
Investigation is often a team activity, competent investigator should have and We offer two Continuing Professional
with members contributing their own how to evaluate them. As part of your Development courses in accident
knowledge, experience and skill. In all emergency planning, you can use the investigation – ‘Incident investigation
cases, the investigation should include factors outlined in Appendix C to assess and risk control’ (two days) and
input from management and the the competence of potential ‘Accident/Loss investigation and
workforce. The competence of investigators. evidence gathering’ (four days). Have a
investigators is fundamental to the look at section 10 (page 15) for more
effectiveness of the investigation. The NEBOSH Diploma and all degrees details.
recognised by IOSH include basic
The lead investigator and all supporting knowledge about accident, incident As we discussed earlier, competence
team members should have the and illness investigations. There are requires a range of skills, experience
analytical, interpersonal, technical and also NVQ qualifications which include and knowledge. None of these
administrative skills needed to carry out basic competence in accident qualifications on its own provides the
the investigation. They should be able investigation: competence you need to investigate
to form an independent view and work - NVQ Health and Safety Level 4, hazardous events – you also need to
well with other people and Element H10 – Reactive Monitoring have been significantly involved in a
organisations who have an interest in (primarily for in-house advisers) range of minor and major
the investigation. - NVQ Health and Safety Level 5, investigations.
Element R3 – Investigating
In Appendix C (page 18), we offer Accidents and Ill Health (primarily
some guidance on the attributes a for regulators).
7 How to avoid common failings
in investigations
Organisations can fail to benefit from - not using a recognised analysis If you follow this guidance, together
investigations for a number of reasons. method to move from immediate to with the more detailed information
These often boil down either to not root causes we’ve referred to, you can make sure
completing the investigation properly - not identifying the root causes, your organisation responds well to
or failing to learn the lessons from the including management failures accidents and incidents. In Appendix
investigation report. Other common - not making sure that the D, there’s a checklist to help you avoid
problems include: recommendations are proportionate, the common pitfalls of investigations.
- not appointing a suitably address the root causes, and that the
competent investigator or team action plan is SMARTT
- not involving relevant management - not implementing recommendations
and workforce representatives or reviewing their effectiveness in
- not setting an adequate timetable tackling the identified root causes
for completing the investigation - not adequately communicating the
- not giving the investigation enough findings of the investigation,
resources, including time and including developing ways to make
specialist knowledge sure they stay in the ‘organisational
- not maintaining an independent memory’, such as during inductions
and objective view of new employees, including senior
- not reviewing risk assessments as managers, and amending policies
part of the investigation and procedures.
12
15. 8 Good practice in investigation reporting
Your investigation report should have - identify the immediate and root You can get more detailed advice on
the clear aim of preventing a similar causes of the hazardous event making recommendations and on the
incident from happening again. Your - comment on any contradictory or content of investigation reports from
report should: missing evidence, and how this guidance targeted at the rail industry,3
- describe the events that led to the affects the identification of root and also from our book Health and
hazardous event and its immediate causes safety: risk management (chapter 6).15
consequences. For serious events, - give clear, prioritised, cost-effective
where the report is likely to be used and SMARTT recommendations to
in future by people who don’t have address the identified causes and
a good knowledge of your prevent the event happening again.
workplace, it’s important to include
clear photographs and diagrams. Make sure that someone in the local
You should also attach copies of management team is responsible for
relevant documents, and keep the timetabling, tracking and applying the
originals in case of future legal recommendations. If disciplinary action
actions is needed, it can be linked to the
- make sure that names, dates and agreed findings of the investigation,
measurements (in metric) are but it should be done by the
recorded accurately appropriate line manager.
- make a clear distinction between
what is established fact and what is
opinion or hearsay
13
16. 9 References
1 Health and Safety Commission. 7 National Institute for Health and 12 UK offshore oil and gas industry.
Management of health and safety at Clinical Excellence. Post-traumatic Incident Alerts Database (previously
work. Management of Health and stress disorder (PTSD): the known as ‘SADIE’).
Safety at Work Regulations 1999 – management of PTSD in adults and www.stepchangeinsafety.net/
approved code of practice and children in primary and secondary stepchange/Incidents.aspx.
guidance (L21). Sudbury: HSE Books, care (Clinical Guideline 26). London: 13 Fatal Accidents and Sudden Deaths
2000. NICE, 2005. Inquiry (Scotland) Act. London:
2 British Standards Institution. Guide to www.nice.org.uk/CG026NICE HMSO, 1976.
achieving effective occupational guideline. 14 Health and Safety Executive.
health and safety performance (BS 8 For England and Wales, see Health Investigating accidents and incidents
18004:2008) – Appendix K, ‘Incident and Safety Executive. Work-related – a workbook for employers, unions,
investigation’. London: BSI, 2008 deaths: a protocol for liaison safety representatives and safety
3 Railway Group Standards. Incident (MISC491). Sudbury: HSE Books, professionals (HSG245). Sudbury:
response planning standard. GO/RT 2003. www.hse.gov.uk/PUBNS/ HSE Books, 2004.
3471, and associated guidance note misc491.pdf; for Scotland, see 15 Boyle A. Health and safety: risk
GO/GN 3671; and Incident Health and Safety Executive. Work- management (3rd edition). Wigston:
management and evidence gathering related deaths: a protocol for liaison IOSH, 2002 (revised 2008).
standard. GO/RT 3472, and (MISC733). Sudbury: HSE Books, 16 Livingston A D, Jackson G and
associated guidance note GO/GN 2006. www.hse.gov.uk/ Priestly K. Root causes analysis:
3672. London: Railway Safety, 2002. scotland/workreldeaths.pdf. literature review. HSE Contract
www.rgsonline.co.uk. 9 Health and Safety Executive. Work- Research Report 325/2001. Sudbury:
4 Railway Group Standards. Accident related deaths: liaison with police, HSE Books, 2001.
and incident investigation standard. prosecuting authorities, local www.hse.gov.uk/research/
GO/RT 3473, and associated authorities, and other interested crr_pdf/2001/crr01325.pdf.
guidance note GO/GN 3673. authorities including consideration of 17 Noordwijk Risk Initiative Foundation.
London: Railway Safety, 2007. individual and corporate Events and conditional factors
www.rgsonline.co.uk. manslaughter/homicide. OC 165/9. analysis manual. Delft: NRIF, 2004.
5 Health and Safety Executive. Work- 2007. nri.eu.com/NRI4.pdf.
related deaths – investigators guide. www.hse.gov.uk/foi/internalops/ 18 US Department of Energy.
2004. Available at the HSE fod/oc/100-199/165_9.pdf. Workbook: conducting accident
Enforcement web page, 10 Health and Safety Executive. HSE investigations (Rev 2). Chapter 7:
www.hse.gov.uk/enforce/ enforcement guide (England & 7.3.4 ‘Events and causal factors
index.htm. Wales) web page, www.hse.gov. analysis’; and 7.4.1 ‘Analytic trees’.
6 Rick J, Kinder A and O’Regan S. Early uk/enforce/enforcementguide/ Washington DC: DOE, 1999.
intervention following trauma: a index.htm; for guidance on www.hss.energy.gov/CSA/CSP/
controlled longitudinal study at Royal investigation priorities for breaches of aip/workbook/Rev2/chpt7/
Mail Group. (IES 435). Brighton: section 3 of the Health and Safety at chapt7.htm.
Institute of Employment Studies, Work etc Act 1974, see 19 Groeneweg J. Controlling the
2006. www.hse.gov.uk/enforce/ controllable: the management of
www.bohrf.org.uk/downloads/ hswact/index.htm. safety (3rd edition). Leiden: DSWD
traumrpt.pdf. 11 Health and Safety Executive. Press, 1996.
Document G – Major incident
response and investigation policy and
procedures. 2001. Available at the
HSE Enforcement web page,
www.hse.gov.uk/enforce/
index.htm.
14
17. 10 More information
Dekker S W A. The field guide to Health and Safety Executive. HSE For more information on the work of
human error investigations. Aldershot: statement to the external providers of coroners in England and Wales, visit
Ashgate Publishing Co, 2006. health and safety assistance. www.justice.gov.uk/about/coroners.
www.hse.gov.uk/pubns/external htm. To find out more about the role
Department of Health. Guidelines for the providers.pdf. of the Procurator Fiscal in Scotland,
NHS: in support of the Memorandum of visit
Understanding – Investigating patient IOSH. Consultancy – good practice www.crownoffice.gov.uk/About/
safety incidents involving unexpected guide: practical guidance on working as roles/pf-role/investigation-deaths/
death or serious untoward harm: a a competent health and safety sudden-deaths.
protocol for liaison and effective consultant. Wigston: IOSH, 2008.
communications between the National www.iosh.co.uk/consultantguide. IOSH offers accident investigation
Health Service, Association of Chief training courses for members and non-
Police Officers and the Health & Safety IOSH. Getting help with health and members. For details, see
Executive. London: DoH, 2006. safety: practical guidance on working www.iosh.co.uk/professional or call
www.dh.gov.uk/en/ with a consultant. Wigston: IOSH, 2008. +44 (0)116 257 3100.
Publicationsandstatistics/ www.iosh.co.uk/consultanthelp.
Publications/PublicationsPolicyAndG If you need professional help during an
uidance/DH_062975. Johnson C W. Failure in safety-critical accident investigation, you can use a
systems: a handbook of accident and health and safety consultant, but you
Health and Safety Executive. ‘Competent incident reporting. Glasgow: University need to be satisfied that they’re
health and safety advice’ web pages. of Glasgow Press, 2003. competent, suitable and fully insured.
www.hse.gov.uk/ www.dcs.gla.ac.uk/~johnson/book. There is an online Occupational Safety
business/competent-advice.htm. and Health Consultants Register
Norton-Doyle J. Accident management (OSHCR) where you can view individual
Health and Safety Executive. and investigation – a practical guide to consultants’ profiles to help you
‘Enforcement guide’ web pages. These managing and reducing workplace choose someone who meets your
provide information on investigation for accidents. London: GEE Publishing Ltd, needs. For more information, visit
health and safety enforcers, for example 2003. www.oshcr.co.uk.
on collecting physical and witness
evidence. www.hse.gov.uk/
enforce/enforcementguide/
index.htm.
15
18. Appendix A – Some relevant UK legislation
For background information to legal and 37 on ‘monitoring’ advise you to Specific and ‘permissioning’
requirements, have a look at section 2 investigate accidents and incidents to regulations
(page 05). establish the immediate and root Control of Major Accident Hazards
causes, so that remedial action can be Regulations 1999 (as amended)
General legislation taken and lessons learned for (See A guide to the Control of Major
Health and Safety at Work etc Act prevention. It also advises you to Accident Hazards Regulations 1999
1974 record and analyse your findings to (as amended) (L111), HSE Books,
(See Health and safety regulation: a identify underlying themes or trends. 2006)
short guide. Sudbury: HSE Books,
2003. www.hse.gov.uk/pubns/ Reporting of Injuries, Diseases and Gas Safety (Management) Regulations
hsc13.pdf) Dangerous Occurrences Regulations 1996
1995 (See A guide to the Gas Safety
Sections 2 and 3 require employers to (See A guide to the Reporting of (Management) Regulations 1996
do all that’s reasonably practicable to Injuries, Diseases and Dangerous (L80), HSE Books, 1996)
protect the health and safety at work Occurrences Regulations 1995 (L73),
of their employees or others who may HSE Books, 1999) Nuclear Installations Act 1965
be affected by their organisation’s (See The licensing of nuclear
activities. It can be argued that this Part G (‘Describing what happened’) installations. 2007. Only available at
implies a duty to investigate the causes of the accident form F2508, which www.hse.gov.uk/nuclear/
of health and safety incidents, so that you must submit for every reportable notesforapplicants.pdf)
future failures can be prevented. event, requires you to describe events
Section 14 gives the Health and Safety that led to the incident, the part Railways (Safety Case) Regulations
Commission the right to direct people played and actions you’ve 2000 (as amended)
investigations and inquiries; sections 18 taken to prevent a similar event (See Railways (Safety Case)
and 19 give authority to enforcers; and happening again. To provide this Regulations 2000 including 2001 and
section 20 gives inspectors their information, you’ll need to carry out 2003 amendments: guidance on
powers, including 20(2)(d) (or article some kind of basic investigation, no regulations (L52), HSE Books, 2003)
22(2)d of the Health and Safety at matter how informal.
Work (NI) Order 1978), which grants These four sets of regulations cover
authority to carry out investigations. Safety Representatives and Safety some UK ‘permissioning regimes’ – in
Committees Regulations 1977 other words, where a formal safety
Management of Health and Safety at (See Safety representatives and safety case or report must be submitted to
Work Regulations 1999 committees – Approved Code of and reviewed by the HSE before a
(See Management of health and safety Practice and guidance on the new facility can be used. Every safety
at work. Management of Health and regulations (L87 – the ‘Brown Book’ – case must be regularly reviewed and
Safety at Work Regulations 1999 – 3rd edition), HSE Books, 1996) updated. The guidance for both duty
approved code of practice and holders and HSE reviewers on what
guidance (L21), HSE Books, 2000.) Under regulation 4(1)(a), an the safety case should contain covers
appointed safety representative’s the need for a structured health and
Regulations 3 and 5 are particularly function includes the right to safety management system, including
relevant. Paragraph 26(a) of the investigate potential hazards and procedures for reporting, investigating
approved code of practice (ACoP), on dangerous occurrences at the and recording incidents, and following
risk assessment, requires that relevant workplace (whether or not they’re up on lessons learned from them.
risk assessments should be reviewed drawn to their attention by the
following near misses, plant or employees they represent), and to
equipment defects, accidents, ill health examine the causes of accidents in
and so on. Arguably, you need to the workplace. Regulation 6 gives
understand the sequence of events and safety representatives the right to
root causes to be able to review how carry out an inspection after a
relevant and adequate your existing notifiable accident, occurrence or
hazard identification (ACoP paragraph disease, so that they can determine
20) and associated controls (ACoP its cause.
paragraph 22(c)) are. Paragraphs 36(b)
16
19. Ionising Radiations Regulations 1999 Evidence used by police and Coroners’ system
(See Work with ionising radiation: regulators Coroners and Justice Act 2009
Ionising Radiations Regulations 1999 Police and Criminal Evidence Act 1984 (Chapter 25), TSO, 2009
approved code of practice and (Chapter 60), HMSO, 1984; and Police
guidance (L121), HSE Books, 2000) and Criminal Evidence (Northern This legislation covers the duties and
Ireland) Order 1989, HMSO, 1989 powers of coroners in relation to
Regulation 25 requires duty holders to investigating deaths and holding
investigate and notify the authorities These are the main pieces of inquests in England and Wales. It also
where possible overexposures have legislation that deal with police requires that where a senior coroner
occurred, so that they can work out powers in the investigation of provides an organisation with a report
any measures they need to take to offences. They define arrestable on ‘actions to prevent other deaths’,
prevent it happening again. offences and cover the manner and the organisation must respond in
circumstances in which criminal writing.
Railways (Accident Investigation and evidence can be gathered in order to
Reporting) Regulations 2005 be admissible in court; among other
(See Guidance on the Railways things, they require suspects to be
(Accident Investigation and Reporting) cautioned before they’re questioned
Regulations 2005, Rail Accident about an alleged offence.
Investigation Branch, 2005)
Criminal Procedure and Investigations
Regulation 5 requires the Rail Act 1996 (Chapter 25), HMSO, 1996;
Accident Investigation Branch to and Criminal Procedure (Scotland) Act
investigate serious accidents and 1995 (Chapter 46), HMSO, 1995
incidents, or those with serious
potential that it decides should be These cover procedures for disclosing
investigated. criminal evidence relating to police
investigations and criminal court
proceedings.
17
20. Appendix B – Legal privilege
This appendix is for information only. Whether documents associated with an them to be ‘at jeopardy’, this account
If you have any doubt about the incident are subject to legal privilege is may be legally privileged and marked
issues raised here, get competent a matter for expert legal opinion. accordingly.
legal advice. Simply declaring a document to be
legally privileged doesn’t mean that it is Solicitors who want to use privilege
Legal privilege describes the status of – employers who try to use ‘privilege’ may suggest particular wording in a
some documentary evidence used in where it doesn’t apply can be report to protect against unfair
legal proceedings. If a document is challenged by other parties in the incrimination if it becomes disclosable
‘privileged’, a party committed to proceedings. Internal incident to a third party. Investigators can
legal proceedings doesn’t need to investigation reports aren’t generally choose whether or not to accept such
disclose it to the other parties privileged because, although civil and suggestions and need to exercise
involved. Legal privilege can only exist criminal actions may take place, the professional judgment to make sure
at the point where a legal adviser purpose of an internal investigation they maintain technical accuracy and
believes that the party he or she is report is to describe how and why the objectivity.
defending is ‘at jeopardy’ (in other incident occurred and to give
words, when they’ve been cautioned recommendations on how to stop it External investigators and prosecutors
by an enforcer or have received a civil happening again (as we outlined in are legally entitled to ask for a copy of
claim). section 2). Therefore, the investigator’s a non-privileged internal investigation
objectives aren’t related in any way to report. However, they may not choose
Examples of possibly privileged legal proceedings that may result from to do this, as they have their own
documents include: the incident. investigation report and also recognise
- correspondence between someone that demanding access to internal
and their legal adviser Although we don’t generally reports can damage the value of future
- other information, letters, emails recommend it, there may be situations internal investigations, and breach the
and documents written ‘in in which organisations don’t conduct trust between internal investigators and
contemplation of proceedings’, ie formal investigations – perhaps their witnesses.
once legal proceedings have because they believe they already
begun and the parties have hired know the cause of the incident. For more information, see
legal advisers. However, if they’re then taken to court www.hse.gov.uk/enforce/
and need evidence for their defence, enforcementguide/investigation/
they may use an investigator to physical-obtaining.htm, paragraphs
provide an account of events for their 33–37.
legal team. If their legal team believes
Appendix C – Competence checklist
A competent investigator needs: investigation and analysis skills, instructing investigators. You need to
- analytical skills – independence, legal and technical knowledge be satisfied that a potential investigator
sound judgment, clear and logical - administrative skills – in time is competent in all the areas covered.
thought processes, good management, reporting, evidence You could ask potential investigators to
observational skills preservation and recording, review the issues and demonstrate
- interpersonal skills – the ability to document drafting, editing. their competence to handle them.
communicate effectively and
appropriately, good interview We’ve created the table on the next Remember – it’s your responsibility for
technique page as a checklist for managers making sure the investigator is
- technical skills – effective responsible for selecting and competent.
18
23. Acknowledgments
Our Technical Committee would like to Thanks also to consultees for their
thank the working party that produced contributions:
this guide: Dr Tony Boyle – Consultant, HASTAM
Ian Waldram (Chair) – Director, DI Nigel Niven – Major Crime
SHEQuality Ltd Department, Hampshire Constabulary
Martin Allan – Managing Director, Dr Jo Rick – Programme Director,
Martin Allan Partnerships Ltd Institute of Work Psychology, University
Ian Glendenning – Consultant, Pragma of Sheffield
Consulting Institute of Industrial Accident
DS Henry Harper – Strathclyde Police Investigators
Ian Langston – Director, Kinaston
Associates Ltd
Jonathan Russell – Director of Health We welcome all comments aimed at
and Safety, Department for Work and improving the quality of our guidance,
Pensions (former Head of Policy including details of non-UK references
Enforcement, HSE) and good practices. Please send your
ACC Steve Watts – Hampshire feedback to Luise Vassie, Executive
Constabulary Director – Policy, at
Richard Jones (Administrator) – Policy luise.vassie@iosh.co.uk.
and Technical Director, IOSH
24. This document is printed on chlorine-free paper produced from managed, sustained forests.
IOSH IOSH is the Chartered body for health and safety
The Grange professionals. With more than 38,000 members
Highfield Drive in 85 countries, we’re the world’s largest
Wigston professional health and safety organisation.
Leicestershire
LE18 1NN We set standards, and support, develop and
UK connect our members with resources, guidance,
events and training. We’re the voice of the
t +44 (0)116 257 3100 profession, and campaign on issues that affect
f +44 (0)116 257 3101 millions of working people.
www.iosh.co.uk
IOSH was founded in 1945 and is a registered
charity with international NGO status.
AC/11047/KB/070211/P
Institution of Occupational Safety and Health
Founded 1945
Incorporated by Royal Charter 2003
Registered charity 1096790
