The first hour
Once the injured person has been treated and the area made safe, the investigation starts with preservation. Photograph the scene from several distances and angles before anything is moved. Note the position of equipment, guards, barriers, signs and materials. Identify the witnesses and separate them before they compare accounts. Secure the documents: the RAMS, the permit, the inspection records, the training matrix, the maintenance log for the equipment involved. If the incident is reportable under RIDDOR, or looks as though it might be, do not clear the scene until it is certain the HSE will not want to see it.
The four steps of HSG245
- Gather the information: what happened, where, when, to whom, in what conditions, with what equipment, and what was supposed to happen according to the documents.
- Analyse: establish the sequence of events and ask why at each link in it until the answers move from the workplace to how the work was managed.
- Identify risk-control measures: which controls failed, which were missing, and which would have prevented the incident or reduced its consequences.
- Plan and implement: an action plan with owners and dates, the risk assessment reviewed, the lessons communicated to the people who need them.
Three levels of cause
The immediate cause is the event or condition that directly produced the injury: the unguarded blade, the missing edge protection, the reversing vehicle. The underlying causes are the failures that allowed it: the guard removed for cleaning with no procedure to refit it, the edge protection never planned into the sequence, the banksman reassigned. The root cause is the management failure they share: the pressure on the shift, the assessment nobody reviewed, the supervisor with three sites and no time.
RIDDOR: what must be reported and when
| Event | Duty | Timescale |
|---|---|---|
| Work-related death | Report to the HSE | Without delay; by phone as well as online |
| Specified injury (regulation 4) | Report | Without delay; online within 10 days |
| Injury causing more than 7 consecutive days’ incapacity | Report | Within 15 days of the accident |
| Injury causing more than 3 consecutive days’ incapacity | Record only | In the accident book or equivalent |
| Member of the public taken directly to hospital | Report | Without delay |
| Dangerous occurrence (Schedule 2) | Report | Without delay |
| Occupational disease (regulations 8 to 9) | Report on diagnosis | Without delay |
The responsible person for reporting is the employer of the injured worker, or the person in control of the premises where a self-employed person or member of the public is injured. Employers with ten or more employees must also keep an accident book under the Social Security (Claims and Payments) Regulations 1979, and most keep one regardless.
The report that stands up
A report may be read by an HSE inspector, an insurer’s loss adjuster, a claimant’s solicitor and a coroner, sometimes years later. It stands up when it separates what was found from what was concluded, references every document and photograph by number, records who was interviewed and when, states the causes at all three levels, and ends with an action plan that has since been evidenced as done. It also stands up when it is honest: a report that finds no management failure in a serious incident is treated as a report that did not look.