Introduction
|
| Para
7 |
It
is FOD Policy that investigations will be "provided
with adequate resources and support, including
information, equipment and staffing" |
Work Instruction 1 (Planning)
|
| Key
Instruction 1, para 3 |
All
Investigations must meet the following generic
objectives
| (1) |
identify
immediate and underlying causes; |
| (2) |
ensure the dutyholder takes appropriate
remedial action to prevent reoccurrence; |
| (3) |
evaluate compliance with the relevant statutory
provisions; |
| (4) |
apply
the principles of EMM and take enforcement
action if appropriate. |
|
| Key
Instruction 1, Para 6 |
"As
an investigation proceeds, inspectors should ensure
that it continues to meet its objectives. Periodic
investigation reviews may be necessary with the
line manager for this purpose. Investigation reviews
should take place, after 2 months and thereafter
at 2-monthly intervals until completed" |
| Key
Instruction 1, Para 8 |
"Planning
should also identify: ...
any history of previous advice, enforcement action
or similar incidents involving the dutyholders
identified by, e.g. the incumbent overview;"
|
| Key
Instruction 1, Para 12 |
"Inspectors
should consider using the investigation as the
basis for a preventive inspection, or conducting
a preventive inspection at the same time as an
investigation, so as to maximise the effect of
the intervention with the dutyholder." |
| Key
Instruction 5, Para 28 |
"Inspectors
should also be aware that under existing legislation,
recognised safety representatives are entitled
to investigate the cause of an incident and an
employer has a duty to assist. Inspectors should
contact safety representatives, when appropriate,
to enquire whether they have made a report, as
this may be a useful source of information." |
| Key
Instruction 5, Para 29 |
To
qualify as a RIDDOR investigation ... purposes,
the investigation should, other than in exceptional
circumstances, include a site visit. |
Work Instruction 3 (Conduct and Liaison)
|
| Key
Instruction 3, Para 16 |
"If
the reported incident has resulted in anybody
being hurt then they should be interviewed in
every investigation unless there are exceptional
circumstances preventing this. Interviews should
normally be in person, but may be by phone where
this would not hinder the outcome of the investigation.
If the inspector proposes, for other reasons,
not to contact the Injured Person (IP), they must
agree this with their line manager." |
| Key
Instruction 3, Para 17 and 18 |
The
inspector should inform the injured person (IP)
of the outcome of the investigation. ...As a general
principle, the inspector should interview the
IP as soon as possible after the incident. |
| Key
Instruction 3, Para 23 |
As
a general principle, inspectors should always
try to establish whether people other than those
directly affected were exposed to the same risk(s)
at or before the time of the incident. Evidence
to this effect can add weight to any subsequent
prosecution. |
| Key
Instruction 3, Para 24 |
As
a general principle, inspectors should interview
all witnesses as soon as possible after the incident
so that:
| (1) |
details
will be easier to recall; |
| (2) |
there
will have been less opportunity for collusion
between witnesses, or attempts to influence
their evidence; |
| (3) |
it
should be possible to use their natural
desire to cooperate in finding out what
has gone wrong. |
|
| Key
Instruction 5, Para 26 and 27 |
Inspectors
should make early contact with employees' representatives
to let them know that an investigation is taking
place ... Employee representatives may also be
potential witnesses. They may be able to give
information about:
| (1) |
working
practices and events prior to the incident; |
| (2) |
changes in conditions following the incident; |
| (3) |
other
witnesses management may be unaware of
|
| (4) |
previous
near misses or similar incidents; and |
| (5) |
relevant
minutes of safety meetings. |
|
Work Instruction 4 (Establishing Circumstances)
|
| Key
Instruction 1, Para 2 |
In
the majority of cases, the objectives of an investigation
are achieved by using the following range of methods:
| (1) |
direct
observation; |
| (2) |
interviewing
witnesses; |
| (3) |
taking photographs and measurements; |
| (4) |
obtaining
relevant data, documentation and physical
evidence; and |
| (5) |
sampling
or forensic or other analysis. |
|
| Key
Instruction 1, Para 3 |
As
the investigation progresses, inspectors should
test information and evidence obtained against
the lines of enquiry identified, and compare them
to the legal requirements relevant to the circumstances,
and any relevant benchmarks. They should identify
any gaps in the information or evidence together
with appropriate source(s) of further information
or evidence required. |
| Key
Instruction 1, Para 4 |
Inspectors
should consider issuing enforcement notice(s)
(having first applied the principles of EMM) at
a first visit, if conditions which led to an incident
have been allowed to continue or are repeated
elsewhere. If the inspector institutes a prosecution
following an incident, it may be appropriate to
allege a further offence on the day of the investigation,
if suitable preventive measures have not been
taken. The issuing of notice(s) will reinforce
such action. |
| Key
Instruction 1, Para 5 |
During
an investigation, inspectors should be aware of
other potential breaches not related directly
to the investigation and consider enforcement
action where appropriate. |
| Key
Instruction 1, Para 7 and 9 |
Investigating
inspectors should identify, and eliminate or confirm,
all reasonable lines of enquiry relevant to the
objectives of an investigation.... Failure to
identify or adequately follow up all reasonable
lines of enquiry can result in a failure to take
appropriate enforcement action and result in external
criticism. |
Work Instruction 5 (Interviewing)
|
| Key
Instruction 2. para 5 |
After
initial discussions, inspectors should not interview
senior or other managers in depth (unless they
are direct witnesses to the accident) until factual
matters relating to the accident have been established. |
| Key
Instruction 2. para 6 |
Inspectors
should plan the order in which they interview
witnesses to ensure that the findings and outcome
of the investigation are not compromised. They
should interview the following first (not necessarily
in the order given), so far as is relevant and
appropriate
| (1) |
any
injured people; |
| (2) |
workers
with knowledge of the particular incident
being investigated; |
| (3) |
other workers who have knowledge of the
same or similar work (on the same day, or
before or after the incident), and who can
confirm, or contradict, any shortcomings
which apparently led to the incident; |
| (4) |
any
trade union and safety representatives with
relevant knowledge; and |
| (5) |
other
witnesses to the incident, e.g. members
of the public |
|
| Key
Instruction 2. para 7 |
Next, inspectors should interview supervisors
and similar lower-level management, who have background
knowledge and may also be able to describe systems
of work and other steps taken to ensure safety.
Question them concerning any instructions they
had been given about the job and the instructions
they had given to those carrying out the work
activity. The interview should try to determine
whether they were aware of actual as opposed to
correct practices. Depending on what information
such interviewees provide, reinterviewing of workers
etc may be necessary. |
| Key
Instruction 2. para 8 |
Inspectors
should then assess information obtained from employees,
if necessary with the assistance of specialist
or other expert help. This will clarify the information
they can gain from further questioning, before
they interview managers. |
| Key
Instruction 2. para 9 |
Finally,
inspectors should interview senior managers, directors
and individual dutyholders who can make admissions
either in relation to their own or a company's
liability. |
| Key
Instruction 2. para 10 |
Inspectors
may not decide, until a late stage in an investigation,
to collect evidence with a view to legal proceedings.
Observing the hierarchy of interviewing described
above will help to ensure that the outcome of
any investigation is not unwittingly prejudiced
before they reach such a decision. |
Work Instruction 6 (Establishing Physical Circumstances)
|
| Key
Instruction 1. para 7 |
Inspectors
should identify and preserve physical evidence
as early on in the investigation as possible.
In cases of fatal or major accidents the police
will attend the site first. They will preserve
the scene and will make initial enquiries which
can establish physical evidence such as which
machine or piece of equipment was involved. They
can also arrange for their technical support staff
to take photographs and measurements should items
of plant or equipment need to be removed before
an HSE inspector arrives at the scene. |
| Key
Instruction 1. para 9 |
Inspectors
have the power under HSW Act s.20(2)(e) to direct
that premises, or any part of them, or anything
in them, be left undisturbed for so long as is
reasonably necessary for the purposes of the investigation. |
| Key
Instruction 1. para 11 and 12 |
When
appropriate, inspectors should make informal arrangements
with the employer to ensure the scene remains
undisturbed without issuing a formal notice. ...
If an inspector is unable to attend site and the
occupier is unable to leave undisturbed for reasonably
practicable reasons, then the inspector should
tell the occupier to take photographs of the scene
and keep any relevant physical evidence, at the
very least. |
| Key
Instruction 1. para 16 |
In
most investigations all necessary evidence will
be obtained from the dutyholders (particularly
documentary evidence), employees, other first-hand
witnesses of fact and HSE inspectors. Some investigations,
however, will require more complex enquiries,
and inspectors should be aware of and utilise,
where appropriate, other sources of information
and evidence. They include:
| (1) |
manufacturers/suppliers; |
| (2) |
other
enforcement agencies; |
| (3) |
phone
records and details of subscribers; |
| (4) |
vehicle
registered keeper; |
| (5) |
bank
transaction details (proof of ownership); |
| (6) |
plans,
drawings and calculations; |
| (7) |
reasonably practicable (accepted) industrial
practice, confirmed usually by the SG; |
| (8) |
Companies
House records (annual returns); and |
| (9) |
competent persons. |
|
Work Instruction 8 (Assessment of Evidence)
|
| Key
Instruction 1. para 2 |
Inspectors
should continually assess the evidence collected
in order to determine whether the objectives of
the investigation are likely to be achieved (see
Work
instruction 1 Key activity 1). They should
identify potential offence(s) at this stage. They
should identify elements necessary to prove an
offence(s) against existing evidence. Inspectors
should also ask the following questions when assessing
evidence; does it:
| (1) |
establish the circumstances satisfactorily
or do grey areas or inconsistencies exist? |
| (2) |
provide
sufficient evidence to prove a breach, i.e.
are all points to prove covered? |
| (3) |
provide sufficient information to establish
no breach has been made? |
| (4) |
identify
all reasonable lines of enquiry? |
| (5) |
identify
any potential defences? |
| (6) |
contain sufficient support from other sources
such as physical evidence and expert witnesses? |
|
| Key
Instruction 1. para 4 |
Assessment
of evidence may identify other witnesses who may
be able to offer more information concerning underlying
causes/management issues, e.g. supervisors/managers.
Evidence from such witnesses may add considerable
value. |
| Key
Instruction 1. para 6 |
Inspectors
should also verify information and evidence obtained
to date. Interviews with witnesses or statements
will usually form the bulk of the information
and evidence collected so far. It should be reviewed
to ensure it is reliable and accurately reflects
the circumstances. |
| Key
Instruction 1. para 8 |
Inspectors should, so far as possible, and to
the extent appropriate in the circumstances, determine
the truth and accuracy of a witness's evidence
by:
| (1) |
checking
it against the evidence of others and against
independent facts; |
| (2) |
assessing
and testing the probability and credibility
of the allegations against other reasonable
explanations for the incident; |
| (3) |
where
necessary, planning to carry out further
interviews with the injured person (IP)
or others using suitable questioning techniques
aimed at helping the interviewee overcome
any difficulty in remembering details. |
|
| Key
Instruction 1. para 9 |
If
the truth of any person's evidence is crucial
to significant enforcement action, i.e. prosecution,
inspectors should be careful to validate the evidence
as described. Inspectors should remember that
the conviction with which details are recounted
is not a measure of their accuracy. If misleading
evidence is not detected during an investigation
it may have serious consequences for any prosecution
resulting from the investigation. |
| Key
Instruction 2. para 17 |
If
an investigation has not been completed after
2 months, a meeting between the line manager and
the investigating inspector should take place.
The purpose of the meeting is to carry out an
investigation review, decide on future action
and identify specific reasonable time-scales,
which should normally be at 2-monthly intervals,
after which another review will be undertaken
if the investigation has not been concluded. The
purpose of the review is to ensure an investigation
does not stagnate and to take into consideration
matters such as witness availability, inquest
hearings and expert witness reports, when agreeing
any extension. |
| Key
Instruction 2. para 22 |
The
systematic application of EMM is defined by the
procedure itself, e.g. all fatal accidents. Inspectors
should apply the principles of EMM to all other
investigations to facilitate the enforcement decision-making
process in relation to the information and evidence
obtained to date. See Enforcement Management Model. |
