Learning the lessons
- 1. Learning the lessons How to respond to deaths at work and other serious incidents direction 10.2
- 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
- 21. Competence checklist Skill area Can the investigator demonstrate that they: Yes/no/ comments Analytical skills can form an independent, unbiased opinion, not unduly influenced by their relationship to the organisation they’re investigating? can stay independent and if necessary criticise peers and/or senior management? can make meaningful observations, notice relevant environmental factors and recognise when detail is important? can gather and analyse information effectively? can look beyond the immediate causes of an event to identify the root causes? can identify what evidence is missing and evaluate contradictory evidence? Interpersonal skills can communicate effectively at all levels of the organisation, and with external and characteristics parties, such as bereaved relatives, the police and regulatory authority, the media and contractors? can use effective interview techniques, including gaining the confidence of ‘reluctant’ witnesses? can manage their own stress when dealing with highly emotive situations? can use tact and sensitivity when communicating? can identify barriers to communication and overcome them? can summarise and explain the objectives, methods, progress and results of the investigation? can influence decision-makers? are assertive enough to express their unbiased professional opinion? Technical knowledge can use appropriate accident causation theories and associated checklists and analysis and skills tools? can use hazard and risk management techniques? know and understand the activities going on at the time of the event? can apply and interpret relevant legislation and guidance? understand the roles and interactions of the police and regulatory authorities? understand the laws on gathering/using evidence, and other relevant legal issues? are aware of sources of evidence (eg equipment, sites, people and documents) and know how to identify, preserve, gather, analyse and record objects and data? can photograph, video or sketch a scene to an adequate quality, or source such expertise at short notice? Administrative skills can manage and/or work within a team? can work effectively with other professionals (eg medical staff, HR professionals and lawyers)? can report their findings concisely and accurately? can record and preserve evidence appropriately? Completed by: Name: Job title: Date: Signature: © IOSH 2008 19
- 22. Appendix D – Hazardous event investigation checklist Use this checklist to avoid some of the common pitfalls of investigations. We recommend that you complete it in two parts – Part A at the time of the event and Part B when you’ve finished your investigation. Part A: Complete at the time of the hazardous event Yes No Are the investigators competent? (See the ‘Competence checklist’ in Appendix C) Have you included arrangements for involving the workforce in your investigation plan? Have you included arrangements for involving the management in your investigation plan? Have you set a remit and timescale for the investigation? Is the timescale realistic – can the investigation be completed without rushing or delays? Have you allocated enough resources (staff, time and money) to the investigation? Completed by: Name: Job title: Date: Signature: Part B: Complete after the investigation Yes No Does the investigation report show that the investigator kept an open mind? Does the report identify what led to the event? Does the report clearly identify the root causes, including any management failures, of the event? Have you reviewed all relevant risk assessments in light of the investigation’s findings? Are the recommendations SMARTT? Have you made plans to implement the recommendations? Have you made arrangements to monitor the implementation of the recommendations? Have you communicated the recommendations to the staff who’ll be directly affected? Have you considered passing on an anonymised version of the investigation results to relevant trade organisations? Completed by: Name: Job title: Date: Signature: © IOSH 2008 20
- 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