Incident Reporting & Investigation

Transcription

1 OHSS: Guidance Incident Reporting and Investigation Incident Reporting & Investigation Contents Scope... 1 Introduction... 2 What to Report... 2 Responsible Person for Making Reports... 3 Registering to Use the Database... 3 Making an Initial Event Report... 3 Full Incident Investigation... 4 Incident Reporting... 5 Further Information and Guidance... 6 Appendix 1 Selection Criteria for Significant Incidents... 7 Appendix 2 Investigation Summary... 8 Appendix 3 Witness Statement... 9 Appendix 4 Incident Investigation Report Scope The purpose of this guidance is to provide further practical advice and guidance on how to report and investigate incidents (accident and near misses). This guidance should be read in conjunction with the management standard which details the responsibilities of different parties to report and investigate incidents. Page 1 of 15

2 Introduction University figures for the last five academic year s show that an average of 227 accidents occur each year to staff, students, contractors and visitors. The University is generally a healthy and safe place to work but the aim is to reduce the number of accidents further. The investigation and analysis of work related incidents forms an essential part of managing health and safety. Blaming individuals is ultimately fruitless and sustains the myth that accidents and cases of ill health are unavoidable when the opposite is true. Learning the lessons from what your investigation uncovers is at the heart of preventing incidents. Identify what is wrong and take positive steps to put it right. Health and Safety Executive guidance HSG245 Investigating Accident and Incidents. What to Report There are four types of events which should be reported: Accidents or near misses (collectively referred to as incidents) Sports injuries First aid reports Fire alarm reports Sports injuries and first aid reports simply record the facts of each event. Incidents and fire alarm reports require notifiers to record initial actions to prevent a recurrence and a full investigation is required for more serious incidents. Any incidents that occur outside of the UK whilst travelling on University business should be reported in the same way as soon as possible. Any incidents that occur to students whilst working on placements i.e. under the direction and supervision of another employer should be reported in the same way as incidents even though the student is not classed as working for the University at the time. Any incidents that occur during downtime on fieldwork should not be reported using the incident database because they are not classed as university business. An should be sent to ohsssafety@ncl.ac.uk and insurance@ncl.ac.uk summarising the incident with any further action considered on a case by case basis. Page 2 of 15

3 Responsible Person for Making Reports A summary of who is expected to report events is provided in the table 1. Event Status of Injured Person Person(s) responsible for reporting Accident or near miss Staff Postgraduate student Undergraduate (campus) Undergraduate (halls) Undergraduate (fieldwork) Contractors Visitors Public Line manager Academic supervisor School office Customer services (reception) Supervising academic/ school office Estate Support Service/ Unit contact Staff meeting visitor OHSS or event organiser Fire Alarm Report n/a Fire Wardens/ Marshals or Security Officers First Aid n/a Fire Aiders Sports injury n/a Students Union or Physical Recreation & Sports Staff Table 1 Summary of Responsible Persons for reporting Registering to Use the Database The first time you use the database you will need to register to be granted access. In order to register please ohss-safety@ncl.ac.uk including your NUIT username and which type of event you want to report (i.e. incident, first aid, first alarm or sports). OHSS will register you and send a confirmatory within 1 working day. Your username and password match your existing NUIT details. Please note there is a live and test database which are clearly labelled on the Incident Reporting webpage and in the database itself. If you would like to practice or want to just see what the database looks like please use the test database. It is easy to accidentally enter a blank event or send an alert to senior managers. The alert facility is disabled on the test system and only OHSS are able to delete blank records from the live system. Making an Initial Event Report When you first log into the database the home screen is the database that you are authorised to see e.g. incidents or fire alarm report. If you are authorised to see more than one database this will be shown in the top right of the screen in a grey task bar as shown below. Page 3 of 15

4 Simply click on the required database and then on the task button create for example: A user guide for entering new incidents is published on the Incident Reporting webpage. As part of the initial incident report you are required to state the incident severity. There are three categories of severity which in turn determines who receives the alert and if a full investigation is required. All incidents and fire alarm reports should receive an initial investigation to carry out any immediate remedial measures for example reporting a physical defect to Estates Support Service. A full investigation is required for all major incidents and some significant incidents. The decision on whether a significant incident requires a full investigation should be made by applying the selection criteria detailed in Appendix 1. Major Significant Minor The most serious types of incidents resulting in Significant incident any incident which results in Minor injury Injury requiring fatalities, lost time (staff days) first aid any person going to hospital Near miss.* Permanent/ disabling injuries minor fire or smoke damage extensive fire or smoke damage * some near misses may be require a full investigation following a joint decision by the incident notifier and OHSS. alert sent to: alert sent to: alert sent to: Executive Board member with Director/ Deputy Head of Unit; health & safety portfolio; Director of Operations Unit Manager Director/ Deputy Director of in Faculty; School Safety Operations in Faculty; Chair of Faculty Health Officer Chair of Faculty Health & Safety & Safety ; ; Head of Unit; Head of Unit; Unit Manager Unit Manager School Safety Officer School Safety Officer Initial investigation required Initial investigation required Initial investigation required Full investigation required Apply incident selection criteria (Appendix 1) Initial action(s) except for serious near misses* Full Incident Investigation Full investigations should be completed for major and significant incidents and serious near misses. The aim of the investigation is to identify what happened and why. Incident investigations can be daunting and OHSS offer an incident investigation training course for any staff members who may be expected to carry out full incident investigations. The course will Page 4 of 15

5 provide staff with the knowledge and tools to conduct an effective investigation. A summary of the different types of evidence that may be examined in the course of an investigation is provided in Appendix 2. It is expected that managers are involved in the investigation process. Managers may delegate investigation actions e.g. examining site of the incident, taking photographs and witness statements to other staff but should be involved in formulating or agreeing the action plan and signing off the investigation report. Two templates are provided to aid investigators including: Witness statement (Appendix 3); Incident investigation report (Appendix 4). These forms replace any existing local investigation templates. The incident investigation report has been designed to be easy to complete by staff who are not trained investigators. The form consists of a series of questions which prompt who you should speak to and what information to gather. The form can be hand written or typed up. The finished form should be scanned (for hand written forms) and uploaded to the incident database (please refer to user guide). The incident investigation should identify the root cause of the incident. The simplest way to identify the root cause is the five whys approach. The Five Whys is a simple problem-solving technique that helps to get to the root of a problem quickly. The Five Whys strategy involves looking at any problem and drilling down by asking: "Why?" or "What caused this problem?" Following this approach five times is usually enough to reach the root cause. The last page of the incident investigation report is an action plan. If any remedial actions are necessary they should be captured in the action plan table. The manager accountable for the service area is responsible for co-ordinating the completion of all actions within agreed timescales. Incident Reporting The incident database includes a number of standard reports. The reporting function is accessed from the menu bar in the top right hand corner of the screen if you are authorised to run reports on incidents. Access to the reporting system is restricted to: Faculty representatives; Heads of Unit; The reporting system provides a summary of incidents for your School or Faculty (depending on your level of access) and provides set graphs and tables showing the incident breakdown organised by academic year (August to July) and quarter (Q1 Aug- Oct, Q2 Nov- Jan, Q3 Feb- Apr and Q4 May- Jul) by: Incident category; Location; Page 5 of 15

6 Incident severity i.e. major/ significant or minor; Body part injured; Total number of accidents. No personal data is provided as part of these reports. OHSS have the ability to run more detailed reports for each database (incidents, sports, first aid or fire alarm reports) if a non-standard or more detailed set of reporting parameters are necessary. OHSS can also access data from the previous SHE incident reporting database dating back to 2001 if a longer reporting period is required. These reports can be exported to Microsoft Excel and ed to Units who can then edit and present the data as required. These reports can take time to produce and the timescale for responses will depend on the availability of OHSS resources. Further Information and Guidance Management Standard Incident Reporting and Investigation; OHSS incident investigation training booking form; Online incident database available at: Health and Safety Executive Investigating Accidents and Incidents: A workbook for employers, unions, safety representatives and safety professionals ; UK statutory instruments - The Reporting of Injuries, Disease and Dangerous Occurrences Regulations 2013; Incident severity summary and significant incidents selection criteria. Page 6 of 15

7 Appendix 1 Selection Criteria for Significant Incidents Any lost time incident (days) to staff No No No No No Initial investigation required Significant Incident Staff/ student or member of the public taken to hospital for treatment Serious injury has been caused or the staff member has been off work for more than 7 consecutive days as a result of the incident Incident has a live civil claim There is a history or trend of similar incidents based on either: Location; Work activity; Category; Injured person. Incident category is part of a Unit or University safety initiative Incident involves a novel or unusual activity which could improve University knowledge or learning Yes Yes Yes Yes Yes Smoke or fire incident Full investigation required Page 7 of 15

8 Appendix 2 Investigation Summary Direct Observations Information from your own direct observation of the site of the accident. Take photographs to aid observations. Layout of premises Equipment e.g. make/ model/ type/ status/ guards/ power status Presence (or absence) of articles or substances General conditions and housekeeping Other person(s) & activities present Reconstruction of incident Measurements and plans Position of injured person/ witnesses at time of the accident Presence of CCTV cameras Assess what you find Check reliability, accuracy Identify and resolve differences Identify gaps in evidence Do you have a clear picture of what happened and why? People to speak to Information from: Injured person Direct witnesses First aider/ fire marshal Other staff or students working in or managing the accident site Documents Information from relevant documents: Accident report form First aider/ fire marshal report (s) Safety policy Risk assessments COSHH assessments Manual handling assessments Staff training records Monitoring records e.g. dust/ noise Maintenance/ test results Previous accident reports Health & safety executive guidance Other best practice guidance Minutes of meetings Standard operating procedures Manufacturer s instructions Page 8 of 15

9 Appendix 3 Witness Statement University of Newcastle Witness statement form This statement is relevant to the Health and Safety at Work etc. Act 1974 and any Regulations made under this Act. Name of Witness: Address: This statement consisting of page(s), signed by me is true to the best of my knowledge and belief and I make it knowing that; if it is tendered in evidence I shall be liable to prosecution if I have wilfully stated in it anything which I know to be false or do not believe to be true. Signature Date: Signed

10 Statement of: Page of Signed Date

11 Witness Statement Page 2 (to be printed back to back with cover page) Statement date Made out in the presence of Position Statement taken in relation to Classification of witness: Staff Student Public Contractor Other state: Page 11 of 15 Incident investigation Version: 2 Owner: AJM Date of creation: 01/2017 Review Date: 01/2020

12 Appendix 4 Incident Investigation Report Incident Investigation Form Newcastle University This form should be signed by the person leading the incident investigation. If you require any assistance in completing this form please contact the Occupational Health & Safety Service (OHSS) on ohss-safety@ncl.ac.uk Section 1: Overview Name of Injured Person(s) School/Institute/Service carrying out investigation Incident Severity Major Fatality Permanent/ disabling injury Major fire Date of adverse event Significant Any lost time (in days) Person going to hospital Fire or smoke incident Click here Minor Minor injury First aid treatment Near miss Section 2: Investigation Information Gathering 1. Where and when did the incident happen? Include building/ room. For outside areas consider aerial map with site of incident marked. 2. Who was injured/ suffered ill health or was otherwise involved with the incident? Include name/ staff or student number if known/ length of service/ status e.g. staff/ student/ contactor/ 3. Were there any direct witnesses to this incident? Have witness statements* been taken? *n.b. a template witness statement form is available on the OHSS website Supporting documents: witness statements from: 4. How did the incident happen? (What activities were being carried out at the time and any equipment involved including make/ model/ serial no) Page 12 of 15 Incident investigation Version: 2 Owner: AJM Date of creation: 01/2017 Review Date: 01/2020

13 Supporting documents/ items: photographs CCTV or video/ audio files Plans Physical evidence e.g. whole of damaged parts of equipment, samples of substances/ clothing or footwear 5. Why did the incident happen? Use the five whys technique to identify root causes 6. Was there a risk assessment and/or standard operating procedure? Was the risk assessment/ SOP adequate and/or followed? Supporting documents/ items: risk assessment(s) including COSHH/ manual handling/ travel risk assessments standard operating procedures manufacturers/ suppliers user guides results of tests e.g. dust or noise monitoring health surveillance records best practice guidance e.g. trade association or Health and Safety Executive guidance 7. Was there anything unusual or different about the working conditions? 8. What injuries or ill health effects, if any, were caused? Page 13 of 15 Incident investigation Version: 2 Owner: AJM Date of creation: 01/2017 Review Date: 01/2020

14 9. Was maintenance, cleaning or housekeeping sufficient? If not, explain why not. Supporting documents/ items: Maintenance contracts Maintenance or cleaning records 10. Was a lack of competency/ training a factor in this incident? Supporting documents/ items: Training records Copy of presentations/ handbooks or other written information provided to staff /students 11. Did the workplace layout influence the incident? 12. What safety equipment and/or personal protective equipment was provided? Was the equipment suitable/ used correctly? Was PPE worn/ compatible with other PPE? 13. Are you aware of any similar incidents? Please give details 14. Is there any other information not detailed above that is relevant to this incident? Now complete your action plan overleaf (if necessary) Page 14 of 15 Incident investigation Version: 2 Owner: AJM Date of creation: 01/2017 Review Date: 01/2020

15 Section 3: Action Plan and Investigation Sign Off This action plan matches the fields provided on the online incident database. The actions should be entered onto the database once agreed. Title Description Allocated to Target Date Click here Click here Click here Click here Click here Click here Click here Comments Task complete Date Completed Y N Click here Y N Click here Y N Click here Y N Click here Y N Click here Y N Click here Y N Click here Signed on behalf of investigation Team Name Signature Members of the investigation team