Incident analysis

Incident analysis: Why a good incident reporting system should be a key part of your safety management system

(RoSPA’s Occupational Safety & Health Journal coverage, February 2015 issue, pg 19, click here to view printed article)

RoSPA. The RoSPA Occupational Safety & Health Journal, January 2015

Things do not always go to plan even in the most organised, well run, safety aware organisations. Louise Hosking discusses why having a good incident reporting system is so important.

Understanding the Problem

Having arrangements in place to understand why an accident or incident has occurred can provide a valuable insight into real issues or difficulties being experienced on the ground. A good incident reporting system may highlight issues which hadn’t been expected. HSG65 describes the framework for any type of business, school or event to adopt as they start to honestly examine their organisational arrangements. This guidance describes the importance of checking standards and refers to the analysis of incident data as Reactive Monitoring.

Minor incidents and near misses can offer a warning that something isn’t quite right, especially where there are repeat minor events which wouldn’t otherwise be considered in isolation. It is true that if someone seeks to claim damages due to injury or ill health as a result of work, they can expect to see documentation relating to it. Leaders should not be discouraged by this; without a strong reporting system, improvements cannot be made.

Work may be required to encourage staff to report. Individuals will not report if they are fearful of repercussions, or if they think that either a colleague or themselves will be blamed. Reports will not be forthcoming if staff do not understand the system in place, what has to be reported, or how to make a report.

As an absolute minimum, organisations should have an accident book available. These can be obtained from any stationary supplier or HSE Books. Under social security legislation, this must be used to record work-related injuries or ill health for which state benefits (including statutory sick pay) could be payable. Under Health & Safety legislation, all incidents relating to injuries or ill health which result in more than 3 days away from work must be recorded.

Making first aiders reporting champions is a good way to ensure that if first aid is required, incidents are reported. Small, low risk businesses should start here.

The information recorded within a standard accident book is basic and it does not encourage further investigation into the reasons why an incident may have occurred; often, the Give the cause section is left blank. It is also designed to record accidents, not near miss issues, which are potentially important as these are warnings that a system of work may have to be examined.

Near misses are events which did not result in injury, but could have under different circumstances. For example, a piece of equipment falls from a mezzanine floor into the space below where people are working, but no one is injured. It can be pure luck which prevents a serious injury when a near miss occurs, so it is important to ensure these are internally reported. As internal arrangements for incident reporting develop and staff awareness grows, near miss reporting will naturally be the next step.

Many organisations create their own internal report forms which includes information expected within the accident book, but also provides additional information to enable trends to be identified. The benefit of this is that specific data can be collated for analysis later.

It is important to ensure the reporting system in use is clear, straight forward and easy to use. If organisations encourage minor incident reporting, the report should be no longer than a page. However, if a more serious incident occurs there must be a system in place for investigating this further, adding additional detail and escalating the matter if necessary.

If further investigation is required, the form used should prompt the person completing it to identify the root cause of exactly why the incident occurred. It can also prompt the person investigating to consider if the incident meets a threshold for reporting under Reporting of Diseases and Dangerous Occurrences Regulation 2013 (RIDDOR.) There are usually multiple reasons why a serious accident has occurred and many opportunities for it to have been prevented. Whilst the individuals directly involved in the incident or in the vicinity should be asked to contribute, their manager or supervisor should undertake an initial investigation escalating this to an incident controller for further review, and when a more detailed investigation or RIDDOR reporting is necessary.

Some organisations create checklists (see below) to assist in investigations. The more serious the incident, the more in depth the investigation.

Immediate Issues Checklist

• Has equipment been taken out of use, labelled /signed & locked off to prevent re-use?
• Have photographs been taken of the area?
• Did a first aider attend? If Yes, who? If no, Why Not?
• Has the first aider provided a Witness Statement?
• Is there a list of everyone who was in the immediate vicinity at the time?
• Has the injured person provided a witness statement or provided information on what happened?
• Has everyone else who witnessed the incident provided information?
• Have notes been made on everything which can be seen in the area including what the injured person was wearing, especially personal protective equipment?
• What was going on immediately before the incident?
• If the incident involved a slip, trip or fall describe the surface condition, any contributing factors and footwear being worn.
• If there was an injury, what actually caused it and what was the nature of injuries?

Next Stage

• If the incident involved work equipment, has it been examined? Has a report or statutory thorough examination been provided?
• Is the equipment log / maintenance record current?
• Were all expected guards or isolation controls in place?
• Could housekeeping or cleaning be an influencing factor?
• Are any routine safety checks up to date and current? Collate and copy records.
• If the incident involved a chemical or hazardous substance, have details been obtained? Is the COSHH RA available?
• Was the incident caught on CCTV? If so, retain this information.
• Check previous incident reports. Has this occurred before?
• What were the general conditions like? Is there sufficient space? Was the weather an influencing factor (was it hot/cold)?
• Was there a safe system, method statement or risk assessment for the activity, and was it being followed? Collate all records.

Management & People

• Was the person or people involved adequately experienced and knowledgeable? Collate all training records.
• Was a lack of supervision involved in the incident? Describe the supervision and management structure in place.
• Did the incident occur as a result of a non-employee (e.g. contractor or visitor) being in a place or location where they were not permitted?
• Did the incident occur as a result of an employee being in a place or location where they were not permitted?
• Did the accident occur because someone broke the rules?
• Did the incident occur because someone made a mistake? If so, could design or another factor be reviewed to prevent a recurrence?
• Did the incident occur due to one of the following?

1. Tiredness, not taking breaks, long shift
2. Lack of Motivation / Boredom
3. Being distracted
4. Being Under too much pressure / too little time
5. Taking substances – medicines, alcohol, drugs

• Is a claim possible? If yes, ensure that your insurer is notified without delay.

Staff at all levels should receive guidance to encourage reporting. If Managers or supervisors become aware of issues which have not been reported, they should prompt and encourage this. For the system to yield useful information, leaders must be careful not to rush to blame individuals unless it is totally justified or incidents will stay hidden. Co-operation with HR departments analysing sick leave absence can also be sought to identify ill health due to the working environment.

Identifying Trends

As an organisation starts to receive reports, information from these can be used to identify trends and common issues. Reports should be centrally collated. This is also a double check that incidents which should be reported under RIDDOR have been.

Larger organisations may choose to establish web based systems for reporting, and there is accident reporting software widely available which will generate reports based on the incident data generated.

For organisations who choose not to go down this route, it is possible to analyse trends and incident rates using a simple excel spreadsheet which counts basic details on each incident.

Examples of some key data which can be used to identify trends may include

• The date of the incident
• The time of the incident
• The role of the person injured
• Where the incident occurred
• The category of person e.g. Employee, Contractor, Visitor, Child
• Whether the incident was RIDDOR reportable
• If it was RIDDOR reportable, under which category? e.g. Death, Member of public taken directly to hospital, or employee over 7 day injury
• What was the injury/ill health? e.g. bruising, cuts, broken bones
• What was the immediate cause? e.g. Slip, trip and fall, lifting / carrying

By using key phrases and codes, data can be examined and counted providing information from which all levels can learn and to assist with managing risk. Schools can find themselves dealing with lots of minor incidents, and it can be difficult to separate minor bumps and scrapes due to normal play from issues which may be due to a lack of supervision or within a particular location. Plotting first aid cases on a plan of the school or playground can show where regular issues are occurring which require further investigation.

RIDDOR reportable incidents can be counted in this way, thus providing an indication of the incident rate for the organisation based on 100,000 employees.

From the top

As part of good safety management, incident statistics should be passed to the board on a regular basis in a format they can understand and which provides useful information on the actual position within the organisation.

There should also be systems in place for providing information on incidents back to staff in an inclusive manner which does not highlight individuals, but helps them to understand the types of issues occurring and why safe systems have been created. Most people find this information interesting and it really can change personal behaviour.

Finally, organisations should carefully consider how results from reactive monitoring will be used as performance indicators. A good internal system relies upon cooperation at all levels. If employees are judged purely by the number of incidents reported, low risk repeat issues or near misses will not be recorded and these can be important warnings to which the company should take heed. By using effective trend analysis, it is possible to prioritise areas of concern and over time the seriousness of issues raised will reduce.

*Louise Hosking is managing director of Hosking Associates, and a chartered safety & health practitioner