Underlying cause less obvious system or organizational reason for an adverse event – happening e.g. production pressures are too great; Pre-start-up m/c checks were not made by supervisors Hazard not considered in RA No MS Pressure of production more important Employee under pressure Any similar incidents in the past? Was there adequate supervision? Which incidents/accidents should be investigated - In fact the main determinant is the potential of the accident to cause harm rather than the actual harm resulting. Accident Investigation: In a minimal investigation, the relevant supervisor will look into the circumstances of the accident/ incident and try to learn any lessons which will prevent future incidents A low level investigation will involve a short investigation by the relevant supervisor or line manager into the circumstances and immediate underlying and root causes of the accident/incident, to try to prevent a recurrence and to learn any general lessons A medium investigation will involve a more detailed investigation by the relevant supervisor or line manager, the health and safety adviser and employee representatives and will look for the immediate, underlying and root causes A high level investigation will involve a team-based investigation, involving supervisors or line managers, health and safety advisers and employee representatives. It will be carried out under the supervision of senior management or directors and will look for the immediate, underlying and root causes. Four basic elements to a sound investigation: 1. collect facts about what has occurred 2. assemble and analyse the information obtained 3. compare the information with acceptable industry and company standards and legal requirements to draw conclusions 4. implement the and monitor progress findings Phases: Direct observation Documents Interviews Investigation form: and location of accident ➤date of accident ➤circumstances cause of accident ➤immediate of accident ➤underlying
Underlying cause – less obvious system or organizational reason for an adverse event happening e.g. production pressures are too great; Pre-start-up m/c checks were not made by supervisors Hazard not considered in RA No MS Pressure of production more important Employee under pressure Any similar incidents in the past? Was there adequate supervision? Which incidents/accidents should be investigated - In fact the main determinant is the potential of the accident to cause harm rather than the actual harm resulting. Accident Investigation: In a minimal investigation, the relevant supervisor will look into the circumstances of the accident/ incident and try to learn any lessons which will prevent future incidents A low level investigation will involve a short investigation by the relevant supervisor or line manager into the circumstances and immediate underlying and root causes of the accident/incident, to try to prevent a recurrence and to learn any general lessons A medium investigation will involve a more detailed investigation by the relevant supervisor or line manager, the health and safety adviser and employee representatives and will look for the immediate, underlying and root causes A high level investigation will involve a team-based investigation, involving supervisors or line managers, health and safety advisers and employee representatives. It will be carried out under the supervision of senior management or directors and will look for the immediate, underlying and root causes. Four basic elements to a sound investigation: 1. collect facts about what has occurred 2. assemble and analyse the information obtained 3. compare the information with acceptable industry and company standards and legal requirements to draw conclusions 4. implement the and monitor progress Phases: Direct observation Documents Interviews Investigation form: ➤date and location of accident ➤circumstances of accident ➤immediate cause of accident ➤underlying of accident findings