NERC HEALTH & SAFETY PROCEDURE NUMBER: 20
ACCIDENT REPORTING AND INVESTIGATION
VERSION NUMBER: 1.1 DATE OF REVISION: 13 SEPTEMBER 2004
DATE OF ISSUE: 12 APRIL 2002
This procedure covers:
• reporting all accidents in the accident book
• reporting to HSE when RIDDOR requires it
• investigating any mishaps which are reported to HSE or which have serious
implications
• modifying procedures or Safe Systems of Work if investigation shows this to be
necessary.
INTRODUCTION
ACCIDENT REPORTING
• The dictionary definition of an accident as “an unforeseen event” is not particularly helpful in
the context of health and safety. It is more useful to categorise such events which happen in
the workplace (referred to as “mishaps” in this procedure) as follows:
• Incident – any unplanned occurrence that leads to damage to property, plant or equipment.
• Accident – any unplanned occurrence that leads to the injury of personnel or other persons
involved in our activities, including diseases or medical conditions contracted as a result of our
activities.
• Dangerous occurrence – any unplanned occurrence that is listed in Schedule 2 of the
Reporting of Injuries, Diseases & Dangerous Occurrences Regulations 1995 (RIDDOR).
• Near miss – any unplanned occurrence (except Dangerous occurrence) that does not lead to
injury of personnel or damage to property, plant or equipment, but may have done in different
circumstances.
In this procedure we use the phrase “accident reporting” or “accident reports” to cover the
reporting of any of the 4 categories listed above.
We require staff to report all mishaps which occur at work in any of the categories listed above.
Most NERC Sites use the Stationery Office accident book ISBN0-S176-2603-2, for this purpose; it
combines the requirements of social security and health and safety regulations. The Stationery
Office book is not wholly satisfactory, but we suggest that those sites using it continue to do so
until a better system is developed. This will probably be an electronic system based on the one
being set up for BAS.
Under RIDDOR, NERC is required to report certain categories of mishap to the Health & Safety
Executive (HSE). In this procedure, these are referred to as “reportable accidents”. The
regulations use different definitions from the ones shown above.
Each local safety adviser has a copy of the HSE’s Guide to RIDDOR and pads of the forms used
for notifying HSE of reportable accidents to HSE. Reporting is more easily done via the web (For
further information regarding Dangerous Occurrences can be found on the website:
http://www.riddor.gov.uk/ ) or Telephone (0870 1545500). The guide gives detailed definitions of
“reportable accidents”, which are summarised in Appendix I.
NERC HEALTH & SAFETY PROCEDURE NUMBER 20 PAGE 1 OF 12
INVESTIGATION
All mishaps recorded in the accident book should be investigated. Informal investigation will be
sufficient for minor mishaps. Major mishaps, included all those reported to HSE under RIDDOR,
should be formally investigated using the following system. A team consisting of a senior
manager, a member of the site administration staff and the local safety adviser should investigate
any accidents which are reported to HSE, and any other accidents which have serious
implications. A Union Side safety representative should be invited to be a member of any
accident investigation team. The team should produce a written report which should make
recommendations for preventing a recurrence of the accident and a timescale for implementing
the recommendations.
You must report all accidents to the local Accident Reporting System
NERC HEALTH & SAFETY PROCEDURE NUMBER 20 PAGE 2 OF 12
CONTENTS:
• Operational procedure
• Roles and responsibilities
• System flow diagram What might go wrong? – probable sources of system and
individual failure
• Management, monitoring and auditing
Appendices:
• Appendix I: Summary of Regulations
• Appendix II: Specific HSE guidance
NOTE:
The law requires all mishaps in the UK to be reported to the employer, and specified serious
mishaps to the HSE. Mishaps which occur on ships must additionally be reported under the
separate arrangements set out in current merchant shipping legislation and “M” notices.
Mishaps which happen to staff working abroad should be reported in the same way as if they
were working in the UK.
Acknowledgements: this procedure is based on material produced by Richard Pope,
Neil Wilson and the Institution of Occupational Safety & Health.
NERC HEALTH & SAFETY PROCEDURE NUMBER 20 PAGE 3 OF 12
OPERATIONAL PROCEDURE Ï
Management involvement
Management is responsible for ensuring that:
• all mishaps are recorded to the local accident reporting system
• the book is monitored regularly
• mishaps falling within the scope of the RIDDOR Regulations are reported to HSE
• mishaps reportable to HSE, and other mishaps with serious implications, are investigated
• recommendations arising from investigation reports are acted on.
Availability of accident books
Keep accident books where they are easily available to staff. Staff will normally record
mishaps themselves unless they are incapacitated, in which case a colleague or manager
must make the record. Once the information has been entered into the book, to comply with
the Data Protection Act this page should be removed and passed to the appropriate
person/department that looks after these records.
Quarterly returns to Swindon Office
An electronic form will be e-mailed to the relevant person at each Site to record all accidents,
incidents and near misses that occurred during each quarter (end of March, June, September
and December). This form should then be returned to the assistant NERC Safety Adviser at
Swindon. We recommend that Research Centres should also carry out their own monitoring
to identify trends in mishaps. The information is needed in order to:
• compile returns and statistics for the NERC Safety Committee and Audit Committee
• enable the NERC Safety Adviser to monitor trends
• enable Research Centre Directors to take remedial action.
Monitoring of accident reports
The relevant nominated person/s should check the accident reports regularly – ideally weekly
– to ensure that;
• remedial action has been taken where necessary
• RIDDOR mishaps are reported to HSE
• RIDDOR and other serious mishaps are investigated.
Investigation team
Minor mishaps should be investigated informally by the line manager, using the principles set
out below. The Research Centre Safety Director should appoint a team to investigate major
accidents, which include those defined as “reportable accidents” in Appendix I and any others
which have serious implications. A team, normally consisting of a senior manager, member
of the Site administrative staff and local safety adviser, should carry out investigations and
produce written reports. A Union Side safety representative should be invited to be a
member of any accident investigation team. The team’s aims should be to determine:
• the chain of events leading up to the accident
• the causes of the accident
• contributory factors which affected the seriousness of the consequences
• remedial actions to prevent a recurrence
• risk classification (see NERC Procedure no 12, Risk assessment & risk management)
• breaches of the law or NERC Procedures
• whether NERC policies or Procedures need to be amended.
At least one of the staff involved in investigations must understand the reporting regulations,
and have a working knowledge of any other regulations which apply to the activity being
carried out when the mishap happened.
Dealing with the aftermath of the accident
The most senior manager available should deal with the emergency promptly and positively:
NERC HEALTH & SAFETY PROCEDURE NUMBER 20 PAGE 4 OF 12
• take control at the scene
• call for emergency services if necessary
• take action to prevent secondary accidents
• identify sources of evidence at the scene
• prevent evidence from being tampered with or removed
• decide who should be notified.
Collecting evidence for the investigation
Collect relevant information:
• look at the overall picture first
• interview witnesses separately – to ensure that each tells their own story without influence
from others
• interview at the scene whenever possible
• put witnesses at their ease – you are establishing what happened, not allocating blame
• ask questions to draw out information
• feedback to witnesses what you understand they said, to check that your version is
correct
• take photographs
• encourage witnesses to let you know if they subsequently remember anything else that
may be relevant.
Gathering information
• Keep a camera and the other equipment listed below in a grab bag kept in a specified
place so that it is always available for immediate use
• take a notebook or clipboard with paper
• take tie-on labels, permanent markers, sealable plastic bags and containers to label and
collect items which need to be examined or used as evidence
• take photographs of the accident area
• preserve as evidence anything which appears abnormal, such as distorted pieces of
machinery, foreign objects, items showing signs of spillage or leakage
• examine paper evidence such as condition reports, maps or plans, specifications for
equipment, maintenance reports, suppliers’ manuals, competence and training records.
Photography
At the scene of the accident, photographs can record:
• orientation of the scene
• weather conditions
• witnesses’ view of the scene
• relative positions of debris
• evidence of deterioration, abuse, lack of maintenance of equipment.
Photographs can also be used later in the investigation to illustrate:
• dismantling of equipment
• the sequence of failure, e.g. fatigue failures in metal
• evidence overlooked, or hidden, earlier in the investigation
• the written report.
Witnesses
• interview them separately so that they can speak freely, without embarrassment and with
no influence from others
• ask open questions and do not lead witnesses
• interview them at the scene of the accident if possible
• make the interview as informal and unthreatening as possible
• use feedback at the end of the interview to ensure that you have recorded their testimony
accurately.
Points for investigation team to consider
Analyse and evaluate all significant causes:
NERC HEALTH & SAFETY PROCEDURE NUMBER 20 PAGE 5 OF 12
• establish the immediate causes, e.g. failures to follow procedures, sub-standard
equipment
• establish underlying causes, e.g. personal factors, pressure of work
• determine the most critical causes
• check the adequacy of the management system – were the policy or procedures
adequate, did staff comply with them?
Recommend remedial action:
• consider alternative methods of control
• reduce the likelihood that the event will recur
• mitigate the consequences of the event recurring
• take immediate remedial action, even if it is only a holding one
• take permanent action as soon as possible
• document all your findings in a written report.
Review findings and recommendations:
• the report writer’s manager and the local safety adviser should review the report.
• they should evaluate the quality of the report and give feedback on how it could be
improved.
Monitoring
• check that the recommended remedial actions have been taken on time
• check the effectiveness of these actions
• look for trends in serious events.
Authorisation
The Research Centre Safety Director must sign the completed major event investigation
report to show that he/she accepts its recommendations and requires them to be carried out.
Record actions
When the recommendations have been carried out, the manager responsible must record on
the report the date when the work was completed.
Encourage and monitor feedback
At all stages, encourage anyone involved in an event and/or investigation to give further
information, correct or amplify earlier testimony or comment on the effectiveness of the
measures taken to mitigate the effects of the mishap or prevent its recurrence.
Involve site safety committee
The committee should meet to discuss and review the findings of the investigation team.
NERC HEALTH & SAFETY PROCEDURE NUMBER 20 PAGE 6 OF 12
ROLES AND RESPONSIBILITIES Ï
Director: responsible for:
• ensuring that this procedure is followed
• appointing a senior manager to carry out investigations.
Head of Site/Head of Administration: responsible for:
• ensuring that staff are aware of the need to report accidents
• ensuring that accident reports are checked regularly
• arranging for reportable accidents to be notified to HSE
• participating – or nominating a member of staff to participate – in investigations.
Division/Section/Group/Unit heads: must:
• ensure that their staff enter all workplace mishaps to the local accident reporting system
• notify site head of administration of reportable accidents
Competent persons: at least one of the staff involved in accident investigations must
understand the reporting regulations, and have a working knowledge of any other regulations
which apply to the activity being carried out when the accident happened.
Staff:
• must enter to the local accident reporting system details of any workplace mishap
which affects them, unless they are incapacitated, in which case a colleague or
manager must make the entry
• must inform their line manager.
NERC HEALTH & SAFETY PROCEDURE NUMBER 20 PAGE 7 OF 12
SYSTEM DIAGRAM Ï
Accident Reporting and Investigation
START
ACCIDENT, INCIDENT,
NEAR MISS
IS THIS REPORTABLE
YES NO
UNDER RIDDOR
ENTER ACCIDENT,
INCIDENT, NEAR MISS
ENTER ACCIDENT,
TO LOCAL ACCIDENT
INCIDENT, NEAR MISS TO
REPORTING SYSTEM
LOCAL ACCIDENT
REPORTING SYSTEM
IS THE ACCIDENT,
INCIDENT, NEAR MISS
YES DEEMED SERIOUS
REPORT ENOUGH TO WARRANT
ACCIDENT TO AN INVESTIGATION
RIDDOR
INVESTIGATE
INVESTIGATE MAKE
ACCIDENT RECOMMENDATIONS
NO
REVIEW AT LOCAL
MAKE SAFETY COMMITTEE INSPECT ACCIDENT
RECOMMENDATIONS AREA
TAKE ACTION TO PREVENT
REPEAT ACCIDENTS
OCCURING
REFER TO
NERC LEVEL
CONTINUE TO REVIEW
ACCIDENT REPORT BOOK
NERC HEALTH & SAFETY PROCEDURE NUMBER 20 PAGE 8 OF 12
What might go wrong? – probable sources of system and individual failure Ï
Management:
Failure to record mishap in book: if an mishap is serious or has long-term consequences, staff
may decide to sue NERC for compensation. If the mishap is not recorded and, if appropriate,
investigated, it will be more difficult for NERC to defend the case.
Remedy – Encourage accident/incident near miss reporting.
Failure to notify HSE of a reportable accident: HSE can prosecute NERC or an individual for
failing to notify them of a reportable accident. Remedy – encourage managers to inform site
administrative staff of all serious mishaps so that they can notify HSE without delay if it is a
reportable accident.
Failure to carry out an investigation of a serious mishap: this will also make it more difficult for
NERC to refute a claim for compensation. Remedy – the weekly check of the accident reports
should show up any serious mishaps which have not already been notified to site administrative
staff.
MAKE SURE THE MESSAGE IS CONVINCING, CONSISTENT AND
ENFORCED
Staff:
Failure to record mishap in book: it is important for staff to record mishaps in to the local
accident reporting system. If they fail to do so, and subsequently suffer consequences which
lead them to claim compensation, they may find it more difficult to substantiate their claim.
Remedy – report a mishap as soon as it happens. If you are away from base on fieldwork or
other business, make a note of what happened and report it to the local accident reporting system
as soon as you return to base. If the mishap is serious, contact base and ask your manager to
make an entry on your behalf.
NERC HEALTH & SAFETY PROCEDURE NUMBER 20 PAGE 9 OF 12
MANAGEMENT, MONITORING AND AUDITING Ï
Management:
The management of mishap reporting and investigation requires:
• good, clear lines of communications between staff at all levels
• an awareness of the importance of recording mishaps
• competence in carrying out and reporting on investigations.
Monitoring:
The monitoring of mishap reporting and investigation requires:
• review of the accident records weekly
• managers to ensure that their staff report all mishaps in the accident reports
• reviewing statistics to look for trends.
Auditing:
The auditing of accident reporting and investigation requires:
• checking that staff are complying with this procedure
• assessing management and staff attitudes by interview.
NERC HEALTH & SAFETY PROCEDURE NUMBER 20 PAGE 10 OF 12
APPENDIX I: THE REPORTING OF INJURIES, DISEASES & DANGEROUS Ï
OCCURRENCES REGULATIONS 1995 – Summary
Notes for the site manager
When do I need to act?
Death or major injury
If there is an mishap connected with work and:
• your employee, or a self-employed person working on your premises is killed or
suffers a major injury (including as a result of physical violence); or
a member of the public is killed or taken to hospital;
• you must notify the enforcing authority* without delay (e.g. Telephone). They will ask
for brief details about your business, the injured person and the accident; and within
ten days you must follow this up with a completed accident report form (F2508) either
via the web (http://www.riddor.gov.uk/ ) or in writing using the same form.
• *The enforcing authority may be the HSE or the local council. The name, address
and phone number of the enforcing authority should be shown on the poster entitled
“Health & safety law: what you should know” which must be clearly displayed at every
site.
Over-three-day injury
If there is a mishap connected with work (including an act of physical violence) and your
employee, or a self-employed person working on your premises, suffers an over-three-day injury
you must send a completed accident report form (F2508) to the enforcing authority* within ten
days. An over-three-day injury is one which is not major but results in the injured person being
away from work or unable to do their normal work for more than three days (including non-work
days)
Disease
If a doctor notifies you that your employee suffers from a reportable work-related disease then you
must send a completed disease report form (F2508A) to the enforcing authority*. For further
information regarding Diseases can be found on the website: http://www.riddor.gov.uk/
Dangerous occurrence (near miss)
If something happens which does not result in a reportable injury, but which clearly could have
done, then it may be a dangerous occurrence which must be reported immediately (e.g. by
telephone). For further information regarding Dangerous Occurrences can be found on the
website: http://www.riddor.gov.uk/
All Dangerous Occurrences must be reported within ten days on the web
(http://www.riddor.gov.uk/) or by completing the accident report form (F2508).
The HSE free leaflet MISC310, RIDDOR reporting: information about the new incident centre
describes the ways in which you can now inform HSE of reportable accidents at your site, using
• post
• internet
• phone
• fax.
The aim is to make reporting as simple as possible, to encourage employers to report accidents
which fall under the RIDDOR Regulations.
Definitions of major injuries, dangerous occurrences and diseases are given in the HSE
publication “A guide to the reporting of injuries, diseases and dangerous occurrences”, a copy of
which is held at each site.
NERC HEALTH & SAFETY PROCEDURE NUMBER 20 PAGE 11 OF 12
APPENDIX II: SPECIFIC HSE GUIDANCE Ï
Each site has a copy of the HSE publication A guide to the Reporting of Injuries, Diseases &
Dangerous Occurrences Regulations 1995, HSE Books 1999, ISBN 0 7176 2431 5, price £7.95,
which gives full details of the reporting requirements. Further information can also be found on the
website http://www.riddor.gov.uk/.
NERC HEALTH & SAFETY PROCEDURE NUMBER 20 PAGE 12 OF 12
