Welcome Week 4

Unit 3 Risk & Incident

Management

Learning outcomes	Weeks & Assessment Criteria
LO1 Understand the processes and strategies for identifying hazards and evaluating risk levels when carrying out risk assessments in an organisation.	Week 1AC 1.1. 1.2,1.3
LO1 Understand the processes and strategies for identifying hazards and evaluating risk levels when carrying out risk assessments in an organisation.	Week 2AC 1.4, 1.5,1.6
LO2 Understand the strategies and techniques of risk control. LO3 Understand the models of loss causation, analysis of loss data and the importance of incident investigation	Week 3AC 2.1, 2.2,2.3, 3.1
LO3 Understand the models of loss causation, analysis of loss data and the importance of incident investigation. L04 Understand processes and strategies to manage health and safety incidents in an organisation.	Week 4AC 3.2, 3.3,3.4, 4.1
LO4 Understand processes and strategies to manage health and safetyincidents in an organisation. Assessment Submissions.	Week 54.2, 4.3, 4.4Revision Summary

Week 4 Teaching Plan

Unit 3 Risk & Incident Management

Assessment Criteria Week 4

Key content:

2. Justify the use of quantitative methods in analysing loss data
3. Assess the needs and impacts of reporting of loss events.
4. Explain the importance and impact of incident investigations

4.1 Outline the critical stages for managing incidents in the organisation

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Assessment Criteria

AC 3.2 Activity

3.2 Analysing Loss Data

3.2 Analysing Loss Data Different Types of Loss Data

Main types of accident and incident data

Source: Channing, J, Safety at Work, 2013, p262

2. Analysing Loss Data Different Techniques

For AC3.2, we will look at loss (accident and incident) in relation to injuries and near misses involving employees at work. When analyzing injuries, it is best practice to categorise incidents/injuries into different categories based on the severity i.e.

• Near misses
• Minor accidents i.e. first aid cases with no lost time
• Lost time accidents i.e. employees are off work due to their injuries
• Reportable accidents i.e. employees are off work due to their injuries for more than 3 consecutive days
• Fatalities

3.2 Analysing Loss Data Different Techniques

Trend analysis

The most straightforward method of trend analysis is to plot the numbers of accidents or incidents against a suitable measure of time. However, it is also possible to plot on a graph not just the numbers of accidents and incidents but also some measure of severity.

Typical examples of this sort of measure include days lost through sickness, litres of lost fuel, cost of damage repair, etc. Typical time measures include monthly, quarterly and annually.

Channing, J, Safety at work, 2013, p269

3.2 Analysing Loss Data Trend Analysis

Channing, J, Safety at work, 2013, p269

3.2 Activity

Excel Chemical company Trend Analysis Scenario

The previous types of charts are good for tracking trends but if a change in direction is achieved for any month, you are unable to tell if this is more than a random fluctuation. This is the difficulty and challenge.

Excel Chemical company had in a particular year, 100 accidents, however in the following year the company proposed to carry out the same amount of work with no changes which would affect risk. In these circumstances, senior management expected around 100 accidents in the year following the one for which records were available. Note that they did not expect exactly 100 accidents, but around 100 accidents.

Discussions at management level, projected that if there were 99 accidents or 101 accidents they would be able to say that this was due to random fluctuation and, more generally, anything between say 95 and 105 accidents could also be random. However in this year, accidents reached 85.

Discussion: Is this number due to random fluctuation, or is someone doing something which is

improving risk control and influencing the accident numbers?

3.2 Analysing Loss Data Trend Analysis

We need methods of trend analysis that can take into account, fluctuations in trends which will tell us whether there is poor or good methods of control.

In an ideal world, we would be able to measure changes in risk in an organisation and hence determine how well the

risk was being managed.

For example, the measures would enable us to say such things as ‘despite a 50 per cent increase in risk due to additional work being done, the accidents increased by only 25 per cent’, or ‘there was a 10 per cent reduction in risk because of the new machines and work procedures, but accidents increased by 5 per cent’.

Unfortunately, it is rarely possible to measure risk in this sort of way, so what we have to do in practice is to find some proxy for risk which we can measure and use instead.

3.2 Analysing Loss Data Accident Rates

Accident Frequency Rate

This index gives the number of accidents for every 100,000 hours worked and takes into account variations in the amount of work done. Different numbers of hours worked are used in the formula depending on the jurisdiction e.g. 100,000 in the UK versus 200,000 in the US.

Accident Incidence Rate

This index gives the number of accidents for a no. of employees and is used to take into account variations in the size of the workforce. Different numbers of employees can be used e.g. 100, 1000 etc.

3.2 Analysing Loss Data Accident Rates

Accident Severity Rate

This index gives the average number of days lost from accidents per hours worked.

Ill Health Prevalence Rate

‘Prevalence’ is a term often used to describe

ill-health in terms of the proportion of persons who have the prescribed ill-health condition at a particular time. The rate is calculated as:

The total number of cases of ill-health in the population X 100

the number of persons at risk

The calculation gives the percentage of the population with the disease

2. Uses of Loss Data Trend Analysis Pros/Cons

Pros

• Enables sensible trend analyses to be carried out during periods when changes are being made in the organisation that affect the number employed or the amount of work being done
• Can provide useful safety information
• Enables comparisons between one organisation and another, or between different parts of the same organisation, i.e. enabling comparative analyses to be made

Cons

• Although the versions given previously are in general use, there is no universal agreement as to the basic formula
• Variation on definitions for accidents, employees and hours works, and multipliers used by

organisations

• Depend on the quality of the data on which they are based and the honesty of the person preparing them

Assessment Criteria

AC 3.3 Activity

3. The need for reporting of loss events Legal Requirements

• Accidents and dangerous occurrences are required to be reported to the Health & Safety Authority (HSA) in line with the Safety, Health and Welfare at Work (Reporting of Accidents and Dangerous Occurrences) Regulations 2016 (S.I. No. 370 of 2016).

• The HSA guidance document on these regulations explains why accident and dangerous occurrence reporting is required, what is reportable, what is not reportable, who should make the report and how the report should be made.

3.3 The Reporting Culture

3. Reporting of Incidents

Incidents ⁽¹⁾ are an unsafe occurrence arising out of or in the course of work where no personal injury is caused, or where personal injury requires only first aid treatment

The majority of companies will use the HSA Classification as a guidance but then focus their Policies on accidents and incidents across a much broader criteria – such as below

• Near Miss – no injury occurs but the potential for injury was present
• First Aid Treatment – injury can be treated by on site first aiders
• Medical Treatment – injury needs treatment above first aid
• Lost Time – injured person is absent for one day or more, not including the day of the incident

(1) ILO Recording and notification of Occupational Accidents and Diseases 1996

3.3 Severity of loss events Accident Triangle

3.3 Activity

3. The need for reporting of loss events HSA Reportable Events

1. Only fatal and non-fatal injuries are reportable. Diseases, occupational illnesses or any impairments of mental condition are not reportable (differs from the UK).
2. Fatal accidents must be reported immediately to the Authority or Gardaí. Subsequently, the formal report should be submitted to the Authority within five working days of the death.
3. Non-fatal accidents or dangerous occurrences should be reported to the

Authority within ten working days of the event.

4. Injuries to any employee as a result of an accident while at work where the injury results in the employee being unable to carry out their normal work duties for more than three consecutive days, excluding the day of the accident, must be reported to the Authority.

3. Reporting of Loss Events

HSA definition Under Irish Legislation, accidents* can be classed into one of

two types

1. Reportable
2. Not Reportable

*An accident ⁽¹⁾ that arises out of or in the course of employment that results in personal injury

• Reportable Accident – an accident where the injured person is absent from work for 3 or more days, not including the day of the incident
• Not Reportable – an accident where the injured person is not absent from

work for more than 3 days, or if the 3 days are not consecutive

(1) Guidance on the Safety, Health and Welfare at Work (Reporting of Accidents and Dangerous Occurrences)

Regulations 2016

3. The need for reporting of loss events HSA Reportable Events

‘Dangerous occurrence’ means an occurrence arising from work activities in a place of work that causes or results in –

1. the collapse, overturning, failure, explosion, bursting, electrical short circuit discharge or overload, or malfunction of any work equipment,
2. the collapse or partial collapse of any building or structure under construction or in use as a place of work,
3. the uncontrolled or accidental release, the escape or the ignition of any substance,
4. a fire involving any substance, or
5. any unintentional ignition or explosion of explosives, as may be prescribed.

AC 3.3 Video

1.5 minute video

RIDDOR UK

3. The impact of reporting of loss events on an organisation
   1. Reporting loss events is an essential part of risk management and contributes to risk assessment and monitoring.
   2. By consistently reporting and gathering loss event data, organizations can:

• measure risk exposure more accurately;
• justify the cost of new or improved controls and compare the effectiveness of controls;
• identify trends and lessons to learn over time

3. The impact of reporting tells the enforcing authorities responsible for occupational health and safety (HSA or

HSE and local authorities) about serious incidents.

4. Enforcing authorities and reporting organisation can identify where and how risks arise and whether they need to be investigated.
5. It also allows the HSA (Ireland), HSE (England) and local authorities to target their work and provide advice on how to avoid work-related deaths, injuries, ill health and accidental loss.
6. Information on accidents, incidents and ill health can be used as an aid to risk assessment, helping to develop solutions to potential risks.
7. Records also help to prevent injuries and ill health, and control costs from accidental loss.
8. Improves organisation Safety Culture and continuous improvement of Safety Management System

3.3 The impact of reporting of loss events: What do graphs tell us?

Source: HSA

3. Typical proportion of loss events reported

Source: HSA

AC 3.4 Assessment Criteria

AC 3.4 Activity

4. The importance of incident investigations Why is it important to investigate?

3.4 The impact of incident investigations

3 Main Reasons to avoid accidents

• Moral – no one wants to be injured at work or to become ill from dusts and fumes such as asbestos – we all want to ‘do the right thing’

• Legal – failure to comply with the law can cause problems

• Financial – accidents cost a lot of money including compensation and lost time

4. The impact of incident investigations Moral – individual’s loss following an accident

• Mental strain
• Loss of earnings
• Pain and suffering
• Incapacity from work and impact upon their personal life
• Disability
• Effects on dependants or relatives
• Additional expenditure
• Possible life reduction or loss of life

AC3.4 The impact of incident investigations Legal – potential penalties for an employer/director following an accident

• Employers can receive improvement notices, prohibition notices, or high court closure orders

• In relation to serious offences, if summary charges are brought in the District Court, a person convicted may be fined up to €5,000 and/or imprisoned for a period not exceeding 12 months. If the charges are brought on indictment in the Circuit Court, a person convicted may be fined up to €3m and/or sentenced to imprisonment for a period not exceeding two years.

• Where an offence is proved to have been committed with the consent or connivance of – or can be attributed to any neglect on the part of a director or manager or other officer of the company – that person, as well as the company, will be guilty of an offence and be liable to be proceeded against. If an employer or an indeed an individual is found guilty of a contravention of the Safety Health and Welfare at Work Act 2005, they can be fined or face a prison sentence.

• Two of the fines issued to employers in 2019 were €500,000 and €300,000 respectively

4. The impact of incident investigations

Financial – managing health and safety is good for your bottom line

• Accidents and ill health at work cost €3.2 Billion each year in

Ireland (Source: HSA)

• Cost of accidents to an employer €0 – €3.8 million (Source: HSA)

• Cost of accidents to an employee €0 – €100,000 (Source: HSA)

• Average compensation payout is €31,267 (Injuries Board 2015)

• Studies estimate for every €1 invested in health and safety,

there is a return of €2.20 (ISSA 2013)

4. The impact of incident investigations Summary of Benefits

• The prevention of further similar adverse events. If there is a serious accident, the

regulatory authorities will take a firm line if you have ignored previous warnings.

• The prevention of business losses due to disruption, stoppage, lost orders and the costs of criminal and civil legal actions.
• An improvement in employee morale and attitude towards health and safety. Employees will be more cooperative in implementing new safety precautions if they were involved in the decision and they can see that problems are dealt with.

4.1 Assessment Criteria

4.1 Assessment Criteria

1. Activity Poll

1. Critical Stages for Managing Incidents Investigation Level

1. In a minimal level investigation, the relevant supervisor will look into the circumstances of the event and try to learn any lessons which will prevent future occurrences.
2. A low level investigation will involve a short investigation by the relevant supervisor or line manager into the circumstances and immediate, underlying and root causes of the adverse event, to try to prevent a recurrence and to learn any general lessons.
3. A medium level investigation will involve a more detailed investigation by the relevant supervisor or line manager, the health and safety adviser and employee representatives and will look for the immediate, underlying and root causes.
4. A high level investigation will involve a team-based investigation, involving supervisors or line managers, health and safety advisers and employee representatives. It will be carried out under the supervision of senior management or directors and will look for the immediate, underlying, and root causes.

4.1 Critical Stages for Managing Incidents Decision to Investigate – Table to Assist

Remember you must consider the worst potential consequences of the adverse event (eg a scaffold collapse may not have caused any injuries, but had the potential to cause major or fatal injuries).

4.1 Critical Stages for Managing Incidents Investigation

An effective investigation requires a methodical, structured approach to information gathering, collation and analysis. The findings of the investigation will form the basis of an action plan to prevent the accident or incident from happening again and for improving your overall management of risk.

Your findings will also point to areas of your risk assessments that need to be reviewed. This link with risk assessment(s) is a legal duty.

Source: HSE, Investigating accidents and incidents (HSG245)

1. Critical Stages for Managing Incidents Getting to the Root of the Problem

• Loss – consequences of accident e.g. people (injuries), property (damage)
• Event (accident) – event producing the loss

• Direct (Immediate) Cause of Accident –
  • Unsafe Condition e.g. blocked fire exit . You can see the physical symptom
  • Unsafe Act- e.g. driving a fork truck using a mobile phone, you see the unsafe behaviour

• However acting at this level only will not ensure a recurrence is prevented

• Indirect (Root or Underlying) cause – understanding these will explain why the substandard

condition or act happened

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4.1 Critical Stages for Managing Incidents

To establish the root cause of the incident with a view to putting in place measures to stop the incident from happening again.

Important to ensure all incidents (including near misses) are reported and investigated.

Name some examples of root causes?

Incident investigation level of Analysis

https://www.aiche.org/ccps/introduction-incident-investiga4t5ion

4.1 Critical Stages for Managing Incidents Root Cause Analysis – 5 Why Example

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4.1 Critical Stages for Managing Incidents

Investigation Steps Summary

• Step one: Gathering the information

• Step two: Analysing the information

• Step three: Identifying suitable risk control measures

• Step four: The action plan and its implementation

1. Critical Stages for Managing Incidents Investigation Steps

Step One: Gathering the information

Where, when and who?

1. Where and when did the adverse event happen?

2. Who was injured/suffered ill health or was otherwise involved with the adverse event?
3. Gathering detailed information: How and what?

4.1 Question

1. Critical Stages for Managing Incidents Investigation Steps

Step Two: Analysing the information

• What were the immediate, underlying and root causes?

• What happened and why?

• Checklist/question analysis of the causes

• What if ‘human failings (errors and violations) are identified as a contributory

factor?

1. Critical Stages for Managing Incidents Common Underlying Causes

• Organisational (Procedures) Factors include:

o policy/standards/rules/Emergency Preparedness/Purchasing controls

• Human (Behavioural) Factors include:
• Supervision/competence/attitude/skill/health surveillance

• Technical (Job ) Factors include:
• Equipment (e.g. guarding), Access & Egress (access kept clear of storage items), Materials, Environment (temp, dusts, noise)

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4.1 Critical Stages for Managing Incidents Investigation Steps

Step Three: Identifying suitable risk control measures

What risk control measures are needed/recommended? Do similar risks exist elsewhere? If so, what and where? Have similar adverse events happened before? Give details.

1. Critical Stages for Managing Incidents Investigation Steps

Step Four: The action plan and its implementation

• Which risk control measures should be implemented in the short and long term?

• Which risk assessments and safe working procedures need to be reviewed and updated?

• Have the details of adverse event and the investigation findings been recorded and analysed?

• Are there any trends or common causes which suggest the need for further investigation?

• What did the adverse event cost?

Activity

A.C 4.1: Incident Investigation Exercise – Groups –

10 minutes

• You are the health and safety manager for a large retail organisation. You are about to lead an internal investigation into an incident involving a forklift truck that was driven into a member of staff’s car which was parked in the staff car park.
• Identify the level of investigation required and explain what members of staff need to be involved.
• Outline six examples of information that needs to be gathered as part of the investigation
• Following gathering of the information, outline three further steps needed to complete your investigation, and what the output of each step should be i.e. step 1: gathering the information.
• Output: Find out what happened and what conditions and actions influenced the adverse event.

Essential research reading

4.1 Essential Research

HSE (UK), Guidance Investigating accidents and incidents – A workbook for employers, unions, safety representatives and safety professionals, HSG245 , 2004

HSA under Safety, Health and Welfare at Work (Reporting of Accidents and Dangerous Occurrences) Regulations 2016 (S.I. No. 370 of 2016)

Dr Tony Boyle, Health & Safety Risk Management, Routledge, 2019

Ron C. McKinnon, The Design, Implementation, and Audit of Occupational Health and Safety Management Systems. CRC Press, 2020.p 87

J. Channing, Safety at Work, 2013

Summary

2. Justify the use of quantitative methods in analysing loss data
3. Assess the needs and impacts of reporting of loss events.
4. Explain the importance and impact of incident investigations

4.1 Outline the critical stages for managing incidents in the organisation

Next week

Student forum

1. Use the forum for all student queries in relation to the course. Urgent or personal queries email the Education officer: admin@cmi-Ireland.com
2. Do recommended research reading – Unit textbook and Further recommended reading research from Research Articles Folder.
3. Continue with preparation of the Assignment and Attempt as many questions as possible for the draft.