TABLE OF CONTENTS

Cover Page……………………………………………………………………………..1
Table of Contents………………………………………………………………………2
1. Introduction to Course…………………………………………………………3-5
2. Theory of Health & Safety Management……………………………………....6-8
3. Legal Requirements…………………………………………………………….9-10
4. Hazard Identification & Risk Assessment……………………………………...11-
16
5. Inspections and Audits………………………………………………………….17-
19
6. Incident Investigation …………………………………………………………..19-
34
7. Universal Safety Signs…………..……………………………………………....35-37
8. Conclusion……………………………………………………………………….38

TRM GROUP / ERCTA 2

 INTRODUCTION

The Health and Safety Representative

"A Health and Safety Representative is one who is continually looking out for those
things that could result in illness, injury or even death. As such, it is MORE than a
voluntary position or appointment. Health and Safety Representative do not merely
serve on the Health and Safety team for a given period and then retire. They have
an ongoing interest in the Health and Safety of their fellow workers."

FUNCTIONS OF A HEALTH AND SAFETY REPRESENTATIVE (OBJECTIVES)

x Review the effectiveness of health and safety measures
x Identify Potential hazards and Potential major incidents at the workplace
x In collaboration with his employer, examine the causes of incidents in the
workplace
x Investigate complaints by any employee relating to that employee’s health
and safety at work
x Make representations to the employer or a health and safety committee on
maters arising from paragraphs (a), (b), (c), (d), or where such
representations are unsuccessful, to an inspector
x Make representations to the employer on general matters affecting the
health and safety of the employees at the workplace
x Inspect the workplace, including any article, Substance, Plant, machinery or
health and safety equipment at that workplace with a view to, the health
and safety of employees, at such intervals as may be agreed upon with the
employer provided that the health and safety representative shall give
reasonable notice of his intention to carry out such an inspection to the
employer, who may be present during the inspection;
x Participate in consultation with inspectors at the workplace and accompany
inspectors on inspections of the workplace

TRM GROUP / ERCTA 3

BASIC OCCUPATIONAL HEALTH & SAFETY DEFINITIONS
Before a detailed discussion of health and safety issues can take place, some
basic occupational health and safety definitions are required.

Hazard and risk

Hazard- It is a condition, activity, object or substance that has the potential to

cause harm.

RISK: The probability or likelihood that injury or damage will occur arising from a
hazard to a person, property or environment.

PURE RISK: The risk potential which exists prior to any controls being put in place

RESIDUAL RISK: The risk that continues to remain once risk assessment has been
done and controls have been put in place to mitigate the risk.

SAFETY: is freedom from any hazard or a threat that may lead to injury or ill health of
the person, damage to property or equipment, loss of resources and materials.

NB: Safety is subjective it various from one place to the other meaning that you can
be safe in one place and become unsafe in another area while risk is objective
meaning that it can be measured to come up with a risk value.

HEALTH- A state of complete physical, mental and social well-being, not merely the
absence of disease or infirmity. (WHO)

OCCUPATIONAL OR WORK-RELATED ILL HEALTH -This is concerned with those illnesses

or physical and mental disorders that are either caused or triggered by workplace
activities. Such conditions may be induced by the particular work activity of the
individual or by activities of others in the workplace. The time interval between
exposure and the onset of the illness may be short (e.g. asthma attacks) or long
(e.g. deafness or cancer).

ACCIDENT: it is an incident which has given rise to injury, ill-health or fatality.

INCIDENT: work related event(s) in which an injury or ill health (regardless of severity)
or fatality occurred or could have occurred.

DIFFERENCE BETWEEN ACCIDENT AND INCIDENT

Key Difference: The word accident has a negative implication and could result in
loss of life, or damage to goods. An incident on the other hand can refer to any
event that happens; it could be positive or negative.
Accident and incident are two different words that are often confused and used
interchangeably, however, these words are different from each other and have
different implications.

TRM GROUP / ERCTA 4

NEARMISS: unplanned and unforeseeable incident which could have but did not
result in death or any damage.
Knowledge of near misses is very important as research has shown that,
approximately, for every 10 ‘near misses’ events at a particular location in the
workplace, a minor accident will occur.

TYPES/CLASSIFICATION OF HAZARDS
CHEMICAL HAZARDS; Originates from chemical substances that are potentially
toxic/irritant to the body.
• GASES; Formless fluids that expands to take up space e,g Sulphur Dioxide,
Carbon monoxide, carbon dioxide
• DUST; Coal dust, asbestos. Silica dust etc
• TOXIC SUBSTANCES; Lead, mercury, Pesticides, solvents etc
• LATEX; found in gloves

BIOLOGICAL HAZARDS; Involve working with animals, people or infectious plant

materials e.g People working in hospitals are at risk of inhaling or ingesting bacteria,
viruses and are also at risk of coming in contact with blood or other fluids which can
affect their health. People working with animals (veterinarians/farmers) are also at risk
including gardeners. Hazardous waste collectors are also at risk

PHYSICAL HAZARDS: Are factors within the environment that can harm the body
without necessarily touching it.
These often occur when workers are exposed to loud noise, water/oil spills on the
floor, very high or low temperatures, vibration or radiation. Physical hazards
damages the body and they can also affect your concentration level leading to
accidents.
ERGONOMIC HAZARDS; Occur when the type of work puts strain on the worker’s
body brought about by;
• Working in such conditions as confined space
• Adopting awkward posture or body position while working e.g bending for
a long time
• Poor lighting, poor seating or standing for a long time. Continued
exposure to these conditions could result in eye strain, muscle strain/pain,
back ache, wrist strain, sore shoulders and disabling injuries in future.

PSYCHO- SOCIAL HAZARDS; Develop as a result of work demands resulting in mental

stress
EXAMPLES
• Time Pressure
• Lack of Training
• Sex favours
• Anticipated Rewards
• Lack of control over own jobs
• Intimidation
• Shift patterns

TRM GROUP / ERCTA 5

 THEORY OF HEALTH AND SAFETY MANAGEMENT

1. HEINRICH’S DOMINO MODEL OF ACCIDENT CAUSATION

Herbert W. Heinrich was a pioneering occupational safety researcher, whose 1931

publication Industrial Accident Prevention: A Scientific Approach[Heinrich 1931] was
based on the analysis of large amounts of accident data collected by his
employer, a large insurance company. This work, which continued for more than
thirty years, identified causal factors of industrial accidents including “unsafe acts of
people” and “unsafe mechanical or physical conditions”.

Heinrich is most famous for originating the concept of the “safety pyramid”. He also
developed the “five domino model” of accident causation, a sequential accident
model which represents an accident sequence as a causal chain of events,
represented as dominos that topple in a chain reaction. The fall of the first domino
leads to the fall of the second, followed by the third, etc.1, as illustrated below.

In the first version of this model, published in 1931, the five factors identified were:

x domino 1: ancestry and the worker’s social environment, which impact the
worker’s skills, beliefs and “traits of character”2, and thus the way in which they
perform tasks

x domino 2: the worker’s carelessness or personal faults, which lead them to pay
insufficient attention to the task (see box about “accident-proneness” theory)

TRM GROUP / ERCTA 6

x domino 3: an unsafe act or a mechanical/physical hazard, such as a worker error
(standing under suspended loads, starting machinery without warning…) or a
technical equipment failure or insufficiently protected machinery

x domino 4: the accident

x domino 5: injuries or loss, the consequences of the accident

INTERPRETATION

x This linear accident model is simple and easy to understand. Compared

with the very simplistic analyses that were common at the time (“accident
caused by worker error”), it helped managers to think about and identify
underlying causal factors that could contribute to accidents. Its promise of
allowing the interruption of the accident sequence by acting on underlying
causal factors (“pulling out a domino”) helps to convince people to adopt
the corrective actions suggested by the accident investigation.
x However, the model can contribute to a focus on the search for culprits in
the accident sequence, rather than on a detailed understanding of all the
factors that may have contributed to the accident.

CRITICISM

The domino model is widely seen today as being too simplistic to be a useful tool
to help understand the causal factors of accidents:

x It leads to an excessively simple view of the contribution of human performance

to accidents, and to a focus on training and procedural compliance (including
“behaviour-based safety” programmes), rather than on system design, workload
and incentives.

2. FRANK BIRD'S DOMINO THEORY

Heinrich’s theory of domino sequence is updated by Frank Bird Jr. to explain the
circumstances that lead to losses (injury) in the chronological order of five
dominoes.

1. Lack of control - Management.

2. Basic causes - Origins.

TRM GROUP / ERCTA 7

Immediate causes - Symptoms.
4. Accident - Contact, and
5. Injury/damage - Loss.
Lack of control is the first domino and refers the fourth function of the
management (planning, organizing, directing, controlling and coordinating). It
involves accident investigation, facility inspection, job analysis, personal
communication, selection and training, 'standards' in each work activity identified,
measuring performance by standards and correcting performance by improving
the existing programmes. This first domino may fall due to inadequate standards,
programmes and follow up.
Basic Causes (origins) are (1) Personal factors lack of knowledge or skill, improper
motivation and physical or mental problems and (2) Job factors inadequate work
standards, design, maintenance, purchasing standards, abnormal usage etc.
These basic causes are origin of substandard acts and conditions and failure to
identify them permits the second domino to fall, which initiates the possibility of
further chain reaction.
Immediate causes are only symptoms of the underlying problem. They are
substandard' practices or conditions (known I as unsafe acts and unsafe conditions)
that could cause the fourth domino to fall. These causes should be identified,
classified and removed by appropriate measures.
Accident or incident is the result of unsafe acts or/and unsafe conditions. This point
is the contact stage. Some counter measures employed are deflection, dilution,
reinforcement, surface modification, segregation, barricading, protection,
absorption, shielding etc.
Injury includes traumatic injury, diseases and adverse mental neurological or
systemic effects resulting from workplace exposures. 'Damage' includes all types of
property damage including fire. The severity of losses involving physical harm and
property damage can be minimized by prompt reparative action, salvage in the
case of property damage and fire control devices and trained personnel.

TRM GROUP / ERCTA 8

LEGAL REQUIREMENTS

There are seven pieces of legislation that are concerned with issues of
occupational health and safety in Botswana. These includes:
1. FACTORIES ACT CAP 44:01
• Applies outside Mine Lease Area
• Covers activities defined in the act Manufacturing and Services
• It is Outdated- no amendments that have been do
• MACHI ne on the act
2. MINES, QUARRIES, WORKS and MACHINERY ACT CAP 44:02
• Applies to all the Mines
• Covers activities stipulated in the act mines, quarries and works within the
mines and was last amended in 1998.
3. RADIATION PROTECTION ACT OF 2007
• It deals with all radiation sources within the country and was established
st
on the 1 of April 2007
• It deals with the registration, licensing, importation, inspection and
disposal of radiation sources.
4. PUBLIC HEALTH ACT 63:01
• It deals with heath related issues affecting the Public
• Covers communicable diseases
• It is applicable to all sectors of the economy

5. AGROCHEMICALS ACT (18 OF 1999)

6. POLLUTION CONTROL ACT 65:03

7. ENVIRONMENTAL IMPACT ASSESSMENT ACT 65:07

ILO CONVENTIONS
Botswana has rectified only one ILO convection which is C176 which deals with
safety and health in mines. Those that are not yet rectified includes:

• C155: Convention on Occupational Safety and Health

• C161: Occupational Health Services
• C167: Construction Safety
• C170: Chemicals
• C174: Prevention of Major Accidents Disasters

TRM GROUP / ERCTA 9

SOME RACTIFIED ILO CONVENTIONS IN BOTSWANA

• C176 SAFETY AND HEALTH IN MINES- It provides for Government to

periodically consult with the employer’s and worker’s representatives on
safety and health issues in the mines in order to prevent fatalities, injuries
and ill heath of workers and members of the public.
• C14 WEEKLY REST, (INDUSTRY), CONVENTION 1921- It provides for a day’s
rest out of a working week of seven days.
• C144 TRIPARTITE CONSULTATION (International Labour Standards- It
promotes effective consultation between Government, employers and
workers at national level on all international labour standards.
• C81 LABOUR INSPECTIONS

CHALLENGES FACING BOTSWANA INTERMS OF IMPLEMENTATION OF OHS RELATED

ACTS
• We are currently using outdated Acts
• There is NO OHS policy in Botswana
• OHS practitioners are not licensed
• ILO convections are not put into practice
• There is NO OHS national body

RISK AND HAZARD IDENTIFICATION

TRM GROUP / ERCTA 10

Risk assessment is a careful examination of what, in your work, could cause harm to
people, so that you can weigh up whether you have taken enough precautions or
should do more to prevent harm.
DEFINATION OF CONCEPTS

HAZARD- It is a condition, activity, object or substance that has the potential to

cause harm.

RISK: The probability or likelihood that injury or damage will occur arising from a
hazard to a person, property or environment.

PURE RISK: The risk potential which exists prior to any controls being put in place

RESIDUAL RISK: The risk that continues to remain once risk assessment has been
done and controls have been put in place to mitigate the risk.

FREQUENCY; It is the number of times the event occurs over a given period of time.

SEVERITY: It represents the cost of the damage

EXPOSURE: The extent or the degree to which people and environment are exposed
to a specific risk. It includes contractors, visitors, neighbors, and customers’ e.t.c

RISK MANAGEMENT; The PLANNING, ORGANIZING, LEADING and CONTROLLING of

the company’s assets and activities in ways, which minimize the adverse
operational and financial effects of accidental losses upon the organization.

The risk assessment shall be ‘suitable and sufficient’ and cover both employees and
non-employees affected by the employer’s undertaking (e.g. contractors,
members of the public, students, patients, customers); every self-employed person
shall make a ‘suitable and sufficient’ assessment of the risks to which they or
those affected by the undertaking may be exposed;

LEGAL ASPECTS OF RISK ASSESSMENT

TRM GROUP / ERCTA 11

Any risk assessment shall be reviewed if there is reason to suspect that it is no longer
valid or if a significant change has taken place;
Where there are five or more employees, the significant findings of the assessment
shall be recorded and any particular at risk group of employees identified. (This
does not mean that employers with four or less employees need not undertake risk
assessments.)
The term ‘suitable and sufficient’ is important as it defines the limits to the risk
assessment process. A suitable and sufficient risk assessment should:
• identify the significant risks and ignore the trivial ones;
• identify and prioritize the measures required to comply with any relevant
statutory provisions;
• remain appropriate to the nature of the work and valid over a reasonable
period of time;
• Identify the risk arising from or in connection with the work. The level of detail
should be proportionate to the risk.
NB: The significant findings that should be recorded include a detailed statement of
the hazards and risks, the preventative, protective or control measures in place and
further measures required to reduce the risks present.
THE OBJECTIVE OF RISK ASSESSMENT
The main objective of risk assessment is to determine the measures required by the
organization to comply with relevant health and safety legislation and, thereby,
reduce the level of occupational injuries and ill health.
The important distinction between the direct and indirect costs of accidents is
reiterated here. Any accident or incidence of ill health will cause both direct and
indirect costs and incur an insured and an uninsured cost.
Direct costs are costs that are directly related to the accident. They may be insured
(claims on employers’ and public liability insurance, damage to buildings,
equipment or vehicles) or uninsured (fines, sick pay, damage to product,
equipment or process).
Indirect costs may be insured (business loss, product or process liability) or
uninsured (loss of goodwill, extra overtime payments, accident investigation time,
production delays).

TRM GROUP / ERCTA 12

 THE TYPES OF RISK ASSESSMENT
1) BASELINE RISK ASSESSMENT
It is done in an organization so as to determine its risk for the first time.
It is a once off exercise that covers all the production process of an organization in
order to identify and assess each and every risk exposure. The base line risk
assessment its primary objective is to identify each and every risk exposure in order
to determine a risk value for it e.g. Fire Risk Assessment.
2) ISSUE BASED RISK ASSESSMENT
This form of risk assessment is done after baseline risk assessment and it is triggered
by issues that come up such as change, a severe accident that occurred, to be
consistent with the legislations concerning the risk.
3) CONTINUOUS RISK ASSESSMENT
Takes the form of all formal and informal inspections and observations that takes
place. It is the simplest, yet most powerful or effective type of risk assessment and it
is performed by supervisors or site foreman. It is referred as continuous because it is
a risk assessment that is performed endlessly due to the extreme risk it has to
address primarily produced by rapid/continuous change.

THE STEPS OF RISK ASSESSMENT

1) IDENTIFY THE HAZARDS
Hazard identification is the crucial first step of risk assessment.
Only significant hazards, which could result in serious harm to people, should be
identified. Trivial hazards should be ignored.
A tour of the area under consideration by the risk assessment team is an essential
part of hazard identification as is consultation with the relevant section of the
workforce.
A review of accident, incident and ill-health records will also help with the
identification. Other sources of information include safety inspection, survey and
audit reports, job or task analysis reports, manufacturers ’ handbooks or data sheets
and Approved Codes of Practice and other forms of guidance.

TRM GROUP / ERCTA 13

 2) IDENTIFY THE PEOPLE AT RISK
Employees and contractors who work full time at the workplace are the most
obvious groups at risk and it will be a necessary check that they are competent to
perform their particular tasks. However, there may be other groups who spend time
in or around the workplace.
These include young workers, trainees, new and expectant mothers, cleaners,
contractor and maintenance workers and members of the public. Members of the
public will include visitors, patients, students or customers as well as passers-by.
3) EVALUATE, REMOVE OR REDUCE, AND PROTECT FROM RISK
The identified hazards are converted to risks and the risks will be evaluated in terms
of likelihood/ probability and severity to determine their risk value and controls.
HIERACHY OF CONTROLS

ELIMINATION; ideally is the most effective method of control

x It involves removing the hazard completely in the workplace
x It is very important to eliminate hazards at the DEVELOPING STAGE or the PLANNING
STAGE.
x Should be used whenever possible
SUBSTITUTION; involves replacing one hazardous agent or work process with a less
dangerous one.
x Replacing a dangerous chemical work process with a safer substitution
x Make sure replacement substance is below occupational exposure

ENGINEERING CONTROLS

x It involves designing or changing piece of machinery or workplace (for example,

using proper machine guards) to reduce exposure to hazards.

BASIC TYPES OF ENGINEERING CONTROLS

PROCESS CONTROL; it involves changing the way the job is done to reduce risks

For example

x Applying wet method or vacuuming instead of dry sweeping with broom

x Use brush instead of spray painting

TRM GROUP / ERCTA 14

x Use electric motors instead of diesel to avoid exhaust fumes
x Use automation- less handling of material
ISOLATION/ENCLOSURE; it involves keeping the hazard physically away from the
people
x Hazardous tasks can be moved to a part of the workplace where fewer people will be
exposed
x Total enclosure of the process- TB isolation wards in hospitals
VENTILATION; removes or dilutes air contaminants
GENERALVENTILATION; it is used to prevent the work environment from being too hot,
cold, dry or humid.
LOCAL EXHAUST VENTILATION; remove air contaminants around the work area.
Fans are used to aid ventilation, facilitate air movement in the room
ADMINISTRATIVE CONTROLS; entails altering the way the job is done through policies,
rules and work practices- setting standards and work procedures
x Changing work schedule e.g limiting the amount of time spent at a hazardous job.
x Reducing exposure time e.g changing a work process to a shift
GOOD HOUSE KEEPING
x Keeping a clean and organized workplace
x Removing any hazards such as objects that may trip the worker
x Avoid slipping from oil spills and other similar liquids
PERSONAL HYGIENE
x Employer should provide sanitary facilities were employees take a shower everyday
x Working clothes must be clean at all times
x Washing hands after handling hazardous materials
x Avoid touching lips with contaminated hands and eating in workshops were toxic
chemicals are used.
PERSONALPROTECTIVEEQUIPMENT; it is the least effective method of hazard control.
x Should be used only when other methods cannot hazards sufficiently
x Employees must be trained on the use of P.P.E
x Selected P.P.E must fit the employee, it is intended to protect
x Equipment worn by person at risk includes goggles, respirators, earplugs etc
x
TRM GROUP / ERCTA 15
 4) RECORD, PLAN, INFORM, INSTRUCT, AND TRAIN
Putting the results of your risk assessment into practice will make a difference when
looking after people and your business. Writing down the results of your risk
assessment, and sharing them with your staff, encourages you to do this. If you
have fewer than five employees you do not have to write anything down, though it
is useful so that you can review it at a later date if, for example, something
changes. When writing down your results, keep it simple, for example ‘Tripping over
rubbish: bins provided, staff instructed, weekly housekeeping checks’, or ‘Fume from
welding: local exhaust ventilation used and regularly checked’.
5) MONITORING AND REVIEW
The risk controls should be reviewed periodically. This is equally true for the risk
assessment as a whole. Review and revision may be necessary when conditions
change as a result of the introduction of new machinery, processes or hazards.
There may be new information on hazardous substances or new legislation. There
could also be changes in the workforce, for example the introduction of trainees.
The risk assessment needs to be revised only if significant changes have taken
place since the last assessment was done. An accident or incident or a series of
minor ones provides a good reason for a review of the risk assessment. This is known
as the post-accident risk assessment.

INSPECTIONS & AUDITS

TRM GROUP / ERCTA 16
Inspection is a tool that is used for hazard and problem identification that can result
in injury or loss. Health and safety reps play an important role in helping the
employer identify hazards, through regular health and safety inspections.

TYPES OF INSPECTION
DAILY CHECK: these are either undocumented (no checklist is used) or
documented inspections, made daily prior to start up and shift change, to ensure
the facility and equipment is in a safe condition. All noted unsafe areas should be
restored to a safe condition before employees can resume work.
REGULAR INSPECTIONS; these are inspections done at pre-determined intervals by
SHE representatives using an appropriate checklist. A regular inspection follows a
systematic, established routine, is thorough and covers all workplaces. It covers all
structural installations to ensure that plant, equipment, processes and materials
meet the minimum standard requirements and are in sound condition. This kind of
inspection is documented e.g monthly inspections.
LEGAL COMPLIANCE; this is a documented monitoring function conducted in an
organization to determine legal compliance and to locate and report any potential
or existing non compliances. E,g it is a legal requirement that a competent person
inspect overhead cranes every 36 months.
PLANNED MAINTENANCE SCHEDULE (PROACTIVE); this is a documented list of routine
maintenance tasks which need to be executed at pre-determined intervals. The
objective of this system is the identification of normal and abnormal wear and tear
of equipment and plant.
Examples of planned maintenance schedules include motorised equipment, lifting
gear, pumps and motors, building maintenance (gutters, drains, ground surfaces),
mechanical equipment.

TRM GROUP / ERCTA 17

 BENEFITS OF WORKPLACE INSPECTIONS
x Eliminates accidents
x Prevent injuries
x Reflect a well-run company/organization
x Encourage better work habits and productivity
x Help to control property damage or loss

HOW DOES ONE INSPECT

x Move systematically throughout the given area-make use of all your senses
x Identify hazards-visible, hidden and developing
x Observe deviations from pre-set standards
x Discuss tasks/procedures and risks with colleagues
x Ask for and take note of questions and suggestions on SHE issues
x Record meaningful statements
x Specify non-conformances/non-performance to standards
x Specify exact location, item description etc.
x Make sure hazards associated with actions and procedures are also identified-not
only physical conditions.
AUDITS

It is a systematic, independent and documented process of obtaining audit

evidence and evaluate it objectively to determine the extent which audit criteria
are fulfilled.

INSPECTIONS AUDITS

Frequent Infrequent

Result in list of hazards Focus on strength and

weaknesses

Identify compliance Deep, critical, systematic and

TRM GROUP / ERCTA 18

 independent

Conducted by employees Conducted by an internal and

external

auditor

INCIDENT INVESTIGATION
UNDERSTANDING THE LANGUAGE OF INVESTIGATION
Certain key words and phrases will be used regularly throughout this guide.
‘Adverse event’ includes:
¾ Accident: an event that results in injury or ill health;
¾ Incident:
Near miss: an event that, while not causing harm, has the potential to cause injury
or ill health.
Undesired circumstance: a set of conditions or circumstances that have the
potential to cause injury or ill health, e.g untrained nurses handling heavy patients.
Hazard: the potential to cause harm, including ill health and injury; damage to
property, plant, products or the environment, production losses or increased
liabilities.
Immediate cause: the most obvious reason why an adverse event happens, eg
the guard is missing; the employee slips etc. There may be several immediate
causes identified in any one adverse event.
Consequence:
Fatal: work-related death;
Major injury/ill health: (including fractures (other than fingers or toes), amputations,
loss of sight, a burn or penetrating injury to the eye, any injury or acute illness
resulting in unconsciousness, requiring resuscitation or requiring admittance to
hospital for more than 24 hours;
Serious injury/ill health: where the person affected is unfit to carry out his or her
normal work for more than three consecutive days;
Minor injury: all other injuries, where the injured person is unfit for his or her normal
work for less than three days;

TRM GROUP / ERCTA 19

Damage only: damage to property, equipment, the environment or production
losses. (This guidance only deals with events that have the potential to cause harm
to people.)

Likelihood that an adverse event will happen again:

Certain: it will happen again and soon;
Likely: it will reoccur, but not as an everyday event;
Possible: it may occur from time to time;
Unlikely: it is not expected to happen again in the foreseeable future;
Rare: so unlikely that it is not expected to happen again.
Risk: The level of risk is determined from a combination of the likelihood of a
specific undesirable event occurring and the severity of the consequences (ie how
often is it likely to happen, how many people could be affected and how bad
would the likely injuries or ill health effects be?)
Risk control measures: are the workplace precautions put in place to reduce the
risk to a tolerable level?
Root cause: an initiating event or failing from which all other causes or failings
spring. Root causes are generally management, planning or organizational failings.
Underlying cause: the less obvious ‘system’ or ’organizational’ reason for an adverse
event happening, eg pre-start-up machinery checks are not carried out by
supervisors; the hazard has not been adequately considered via a suitable and
sufficient risk assessment; production pressures are too great etc.
THE CAUSES OF ADVERSE EVENTS
Adverse events have many causes. What may appear to be bad luck (being in the
wrong place at the wrong time) can, on analysis, be seen as a chain of failures and
errors that lead almost inevitably to the adverse event. (This is often known as the
Domino effect.)
These causes can be classified as:
Immediate causes: the agent of injury or ill health (the blade, the substance, the
dust etc);
Underlying causes: unsafe acts and unsafe conditions (the guard removed, the
ventilation switched off etc)

TRM GROUP / ERCTA 20

Root causes: the failure from which all other failings grow, often remote in time and
space from the adverse event (eg failure to identify training needs and assess
competence, low priority given to risk assessment etc).
NB:To prevent adverse events, you need to provide effective risk control measures
which address the immediate, underlying and root causes.

WHY INVESTIGATE?
There are hazards in all workplaces; risk control measures are put in place to reduce
the risks to an acceptable level to prevent accidents and cases of ill health.
The fact that an adverse event has occurred suggests that the existing risk control
measures were inadequate.
Learning lessons from near misses can prevent costly accidents. (The Clapham
Junction rail crash and the Herald of Free Enterprise ferry capsize were both
examples of situations where management had failed to recognize, and act on,
previous failings in the system.) You need to investigate adverse events for a
number of reasons.
LEGAL REASONS FOR INVESTIGATING
To ensure you are operating your organization within the law.
The Management of Health and Safety at Work Regulations 1999, regulation 5,
requires employers to plan, organize, control, monitor and review their health and
safety arrangements. Health and safety investigations form an essential part of this
process.
Following the Woolf Report6 on civil action, you are expected to make full
disclosure of the circumstances of an accident to the injured parties considering
legal action. The fear of litigation may make you think it is better not to investigate,
but you can’t make things better if you don’t know what went wrong! The fact that
you thoroughly investigated an accident and took remedial action to prevent
further accidents would demonstrate to a court that your company has a positive
attitude to health and safety. Your investigation findings will also provide essential
information for your insurers in the event of a claim.
INFORMATION AND INSIGHTS GAINED FROM AN INVESTIGATION
¾ An understanding of how and why things went wrong.
¾ An understanding of the ways people can be exposed to substances or
conditions that may affect their health.
¾ A true snapshot of what really happens and how work is really done. (Workers
may find short cuts to make their work easier or quicker and may ignore rules.
You need to be aware of this.)
TRM GROUP / ERCTA 21
 ¾ Identifying deficiencies in your risk control management, which will enable
you to improve your management of risk in the future and to learn lessons
which will be applicable to other parts of your organization.
BENEFITS ARISING FROM AN INVESTIGATION
¾ 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.
¾ The prevention of business losses due to disruption, stoppage, lost orders and
the costs of criminal and civil legal actions.
¾ 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.
¾ The development of managerial skills which can be readily applied to other
areas of the organization.
While the argument for investigating accidents is fairly clear, the need to investigate
near misses and undesired circumstances may not be so obvious. However,
investigating near misses and undesired circumstances is as useful, and very much
easier than investigating accidents.
Adverse events where no one has been harmed can be investigated without
having to deal with injured people, their families and a demoralized workforce, and
without the threat of criminal and civil action hanging over the whole proceedings.
Witnesses will be more likely to be helpful and tell the truth. (Consider the following: ‘I
mistakenly turned the wrong valve which released the boiling water because the
valves all look the same’ or ‘I don’t know how John was scalded.’ Which is the likely
response to a near miss and which to an accident? More importantly, which is the
most useful?)
It is often pure luck that determines whether an undesired circumstance translates
into a near miss or accident. The value of investigating each adverse event is the
same.
An investigation is not an end in itself, but the first step in preventing future adverse
events. A good investigation will enable you to learn general lessons, which can be
applied across your organization.
The investigation should identify why the existing risk control measures failed and
what improvements or additional measures are needed. More general lessons on
why the risk control measures were inadequate must also be learned.
WHICH EVENTS SHOULD BE INVESTIGATED?
¾ Having been notified of an adverse event and been given basic information
on what happened, you must decide whether it should be investigated and
if so, in what depth.
TRM GROUP / ERCTA 22
 ¾ It is the potential consequences and the likelihood of the adverse event
recurring that should determine the level of investigation, not simply the injury
or ill health suffered on this occasion. For example: Is the harm likely to be
serious? Is this likely to happen often? Similarly, the causes of a near miss can
have great potential for causing injury and ill health. When making your
decision, you must also consider the potential for learning lessons. For
example if you have had a number of similar adverse events, it may be
worth investigating, even if each single event is not worth investigating in
isolation. It is best practice to investigate all adverse events which may affect
the public.
WHO SHOULD CARRY OUT THE INVESTIGATION?
¾ For an investigation to be worthwhile, it is essential that the management
and the workforce are fully involved. Depending on the level of the
investigation (and the size of the business), supervisors, line managers, health
and safety professionals, union safety representatives, employee
representatives and senior management/ directors may all be involved. As
well as being a legal duty, it has been found that where there is full
cooperation and consultation with union representatives and employees, the
number of accidents is half that of workplaces where there is no such
employee involvement.
¾ This joint approach will ensure that a wide range of practical knowledge and
experience will be brought to bear and employees and their representatives
will feel empowered and supportive of any remedial measures that are
necessary. A joint approach also reinforces the message that the
investigation is for the benefit of everyone.
¾ In addition to detailed knowledge of the work activities involved, members of
the team should be familiar with health and safety good practice, standards
and legal requirements. The investigation team must include people who
have the necessary investigative skills (eg information gathering, interviewing,
evaluating and analyzing). Provide the team with sufficient time and
resources to enable them to carry out the investigation efficiently.
¾ It is essential that the investigation team is either led by, or reports directly to
someone with the authority to make decisions and act on their
recommendations.
WHEN SHOULD IT START?
¾ The urgency of an investigation will depend on the magnitude and
immediacy of the risk involved (eg a major accident involving an everyday
job will need to be investigated quickly).
¾ In general, adverse events should be investigated and analysed as soon as
possible. This is not simply good practice; it is common sense – memory is
best and motivation greatest immediately after an adverse event.
WHAT DOES IT INVOLVE?

TRM GROUP / ERCTA 23

 ¾ An investigation will involve an analysis of all the information available,
physical (the scene of the incident), verbal (the accounts of witnesses) and
written (risk assessments, procedures, instructions, job guides etc), to identify
what went wrong and determine what steps must be taken to prevent the
adverse event from happening again.
¾ It is important to be open, honest and objective throughout the investigation
process. Pre-conceived ideas about the process, the equipment or the
people involved in an adverse event may blind you to the real causes.
Question everything. Be wary of blaming individuals.
WHAT MAKES A GOOD INVESTIGATION?
¾ To get rid of weeds you must dig up the root. If you only cut off the foliage,
the weed will grow again.
¾ Similarly it is only by carrying out investigations which identify root causes that
organizations can learn from their past failures and prevent future failures.
¾ Simply dealing with the immediate causes of an adverse event may provide
a short-term fix. But, in time, the underlying/root causes that were not
addressed will allow conditions to develop where further adverse events are
likely, possibly with more serious consequences. It is essential that the
immediate, underlying causes and root causes are all identified and
remedied.
¾ Investigations should be conducted with accident prevention in mind, not
placing blame. Attempting to apportion blame before the investigation has
started iscounterproductive, because people become defensive and
uncooperative. Only after the investigation has been completed is it
appropriate to consider whether any individuals acted inappropriately.
¾ Investigations that conclude that operator error was the sole cause are rarely
acceptable. Underpinning the ‘human error’ there will be a number of
underlying causes that created the environment in which human errors were
inevitable. For example inadequate training and supervision, poor
equipment design, lack of management commitment, poor attitude to
health and safety.
¾ The objective is to establish not only how the adverse event happened, but
more importantly, what allowed it to happen.
¾ The root causes of adverse events are almost inevitably management,
organizational or planning failures.
Look carefully at your health and safety policy and how it is reflected in the
workplace. Do staff understand the health and safety message in general and in
particular those parts that relate to their work? Is something missing from the policy?
Is it implemented, or is management failing to ensure that health and safety
measures remain in place and are effective at all times? If not, your health and
safety policy needs to be changed.
The investigation should be thorough and structured to avoid bias and leaping to
conclusions. Don’t assume you know the answer and start finding solutions before

TRM GROUP / ERCTA 24

you complete the investigation. A good investigation involves a systematic and
structured approach.
INFORMATION GATHERING:
¾ explores all reasonable lines of enquiry;
¾ is timely;
¾ is structured, setting out clearly what is known, what is not known and records
the investigative process.
ANALYSIS:
¾ is objective and unbiased;
¾ identifies the sequence of events and conditions that led up to the adverse
event; n identifies the immediate causes;
¾ identifies underlying causes, ie actions in the past that have allowed or
caused undetected unsafe conditions/practices;
¾ Identifies root causes, (ie organizational and management health and safety
arrangements – supervision, monitoring, training, resources allocated to
health and safety etc).
RISK CONTROL MEASURES:
¾ identify the risk control measures which were missing, inadequate or unused;
¾ compare conditions/practices as they were with that required by current
legal requirements, codes of practice and guidance;
¾ Identify additional measures needed to address the immediate, underlying
and root causes;
¾ Provide meaningful recommendations which can be implemented. But
woolly recommendations such as ‘operators must take care not to touch the
cutters during run-down’ show that the investigation has not delved deep
enough in search of the root causes.
THE INVESTIGATION
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?
GATHERING DETAILED INFORMATION: HOW AND WHAT?
Discovering what happened can involve quite a bit of detective work. Be precise
and establish the facts as best you can. There may be a lack of information and
many uncertainties, but you must keep an open mind and consider everything that
might have contributed to the adverse event. Hard work now will pay off later in the
investigation.
TRM GROUP / ERCTA 25
Many important things may emerge at this stage of the process, but not all of them
will be directly related to the adverse event. Some of the information gathered may
appear to have no direct bearing on the event under investigation. However, this
information may provide you with a greater insight into the hazards and risks in your
workplace. This may enable you to make your workplace safer in ways you may not
have previously considered.
3.) How did the adverse event happen? Note any equipment involved.
Describe the chain of events leading up to, and immediately after, the adverse
event. Very often, a number of chance occurrences and coincidences combine to
create the circumstances in which an adverse event can happen. All these factors
should be recorded here in chronological order, if possible. Work out the chain of
events by talking to the injured person, eye witnesses, line managers, health and
safety representatives and fellow workers to find out what happened and who did
what. In particular, note the position of those injured, both immediately before and
after the adverse event. Be objective and, as far as possible, avoid apportioning
guilt, assigning responsibility or making snap judgements on the probable causes.
Plant and equipment that had a direct bearing on the adverse event must be
identified clearly. This information can usually be obtained from a nameplate
attached to the equipment. Note all the details available, the manufacturer, model
type, model number, machine number and year of manufacture and any
modifications made to the equipment. Note the position of the machinery controls
immediately after the adverse event. This information may help you to spot trends
and identify risk control measures. You should consider approaching the supplier if
the same machine has been implicated in a number of adverse events. Be
precise. Shop floor process and layout changes are a regular occurrence. Unless
you precisely identify plant and equipment, you will not detect, eg that a machine
or particular piece of equipment has been moved around and caused injuries on
separate occasions, in different locations.
4.) What activities were being carried out at the time?
The work that was being done just before the adverse event happened can often
cast light on the conditions and circumstances that caused something to go
wrong. Provide a good description, including all the relevant details, eg the
surroundings, the equipment/materials being used, the number of employees
engaged in the various activities, the way they were positioned and any details
about the way they were behaving etc.
5.)Was there anything unusual or different about the working conditions?
Adverse events often happen when something is different. When faced with a new
situation, employees may find it difficult to adapt, particularly if the sources of
danger are unknown to them, or if they have not been adequately prepared to
deal with the new situation. If working conditions or processes were significantly
different to normal, why was this?
TRM GROUP / ERCTA 26
 Describe what was new or different in the situation. Was there a safe working
method in place for this situation, were operatives aware of it, and was it being
followed? If not, why not? Learning how people deal with unfamiliar situations will
enable similar situations to be better handled in the future.
Was the way the changes, temporary or otherwise, were introduced a factor? Were
the workers and supervisors aware that things were different? Were workers and
supervisors sufficiently trained/experienced to recognize and adapt to changing
circumstances?
6.) Were there adequate safe working procedures and were they followed?
Adverse events often happen when there are no safe working procedures or where
procedures are inadequate or are not followed. Comments such as ‘…we’ve been
doing it that way for years and nothing has ever gone wrong before…’ or ‘…he has
been working on that machine for years and knows what to do…’ often lead to the
injured person getting the blame, irrespective of what part procedures, training and
supervision – or the lack of them – had to play in the adverse event. What was it
about normal practice that proved inadequate? Was a safe working method in
place and being followed? If not, why not? Was there adequate supervision and
were the supervisors themselves sufficiently trained and experienced? Again, it is
important to pose these questions without attempting to apportion blame, assign
responsibility or stipulate cause.
7.) What injuries or ill health effects, if any, were caused?
It is important to note which parts of the body have been injured and the nature of
the injury - ie bruising, crushing, a burn, a cut, a broken bone etc. Be as precise as
you are able. If the site of the injury is the right upper arm, midway between the
elbow and the shoulder joint, say so. Precise descriptions will enable you to spot
trends and take prompt remedial action. For example it could be that what
appears to be a safe piece of equipment, due to the standard of its guarding, is
actually causing a number of inadvertent cut injuries due to the sharp edges on the
guards themselves.
Facts such as whether the injured person was given first aid or taken to hospital
(byambulance, a colleague etc) should also be recorded here.
8.) If there was an injury, how did it occur and what caused it?
Where an accident is relatively straightforward, it may seem artificial to differentiate
between the accident itself (question 3) and the mode of injury, but when the
accident is more complicated the differences between the two aspects become
clearer and therefore precise descriptions are vital.
The mode of injury concerns two different aspects:
¾ the harmful object (known as the ‘agent’) that inflicted the injury; and
¾ The way in which the injury was actually sustained.

TRM GROUP / ERCTA 27

The object that inflicted the injury may be a hand-held tool like a knife, or a
chemical, a machine, or a vehicle etc. The way in which it happened might, eg,
be that the employee cut themselves or spilt chemicals on their skin.
9.) Was the risk known? If so, why wasn’t it controlled? If not, why not?
You need to find out whether the source of the danger and its potential
consequences were known, and whether this information was communicated to
those who needed to know. You should note what is said and who said it, so that
potential gaps in the communication flow may be identified and remedied. The
aim is to find out why the sources of danger may have been ignored, not fully
appreciated or not understood. Remember you are investigating the processes
and systems, not the person.
The existence of a written risk assessment for the process or task that led to the
adverse event will help to reveal what was known of the associated risks. A
judgement can be made as to whether the risk assessment was ’suitable and
sufficient’, as required by law5 and whether the risk control measures identified as
being necessary were ever adequately put in place.
10.) Did the organization and arrangement of the work influence the adverse
event?
The organizational arrangement sets the framework within which the work is done.
Here are some examples; there are many more:
¾ standards of supervision and on-site monitoring of working practices may be
less than adequate; lack of skills or knowledge may mean that nobody
intervenes in the event of procedural errors;
¾ inappropriate working procedures may mean certain steps in the procedures
are omitted, because they are too difficult and time-consuming;
¾ lack of planning may mean that some tasks are not done, are done too late
or are done in the wrong order;
¾ employees’ actions and priorities may be a consequence of the way in
which they are paid or otherwise rewarded;
¾ High production targets and piecework may result in safety measures being
degraded and employees working at too fast a pace.
11.) Was maintenance and cleaning sufficient? If not, explain why not.
Lack of maintenance and poor housekeeping are common causes of adverse
events. Was the state of repair and condition of the workplace, plant and
equipment such that they contributed to or caused the adverse event? Were
the brakes on the forklift truck in good working order? Were spills dealt with
immediately? Was the site so cluttered and untidy that it created a slipping or
tripping hazard? Was there a program of preventative maintenance? What are
the instructions concerning good housekeeping in the workplace? You should
observe the location of the adverse event as soon as possible and judge

TRM GROUP / ERCTA 28

 whether the general condition or state of repair of the premises, plant or
equipment was adequate. Those working in the area, together with witnesses,
and any injured parties, should also be asked for their opinion. Working in the
area, they will have a good idea of what is acceptable and whether conditions
had deteriorated over time. Consider the role the following factors may play:
¾ a badly maintained machine or tool may mean an employee is exposed
to excessive vibration or noise and has to use increased force, or tamper
with the machine to get the work done;
¾ a noisy environment may prevent employees hearing instructions
correctly as well as being a possible cause of noise-induced hearing loss;
¾ uneven floors may make movement around the workplace, especially
vehicle movements, hazardous;
¾ badly maintained lighting may make carrying out the task more difficult;
¾ poorly stored materials on the floor in and around the work area will
increase the risk of tripping;
¾ ice, dirt and other contaminants on stairs or walkways make it easier to
slip and fall;
¾ Tools not in immediate use should be stored appropriately and not left
lying around the work area.
12.) Were the people involved competent and suitable?
Training should provide workers with the necessary knowledge, skills and hands-on
work experience to carry out their work efficiently and safely. The fact that someone
has been doing the same job for a long time does not necessarily mean that they
have the necessary skills or experience to do it safely. This is particularly the case
when the normal routine is changed, when any lack of understanding can become
apparent. There is no substitute for adequate health and safety training. Some of
the problems that might arise follow:
¾ a lack of instruction and training may mean that tasks are not done properly;
¾ misunderstandings, which arise more easily when employees lack
understanding of the usual routines and procedures in the organization;
¾ a lack of respect for the risks involved, due to ignorance of the potential
consequences;
¾ problems due to the immaturity, inexperience and lack of awareness of
existing or potential risks among young people (under18).You must assess the
risks to young people before they start work;
¾ Poor handling of dangerous materials or tools, due to employees not being
properly informed about how things should be done correctly.
NB: People should also be matched to their work in terms of health, strength,
mental ability and physical stature.
13.) Did the workplace layout influence the adverse event?

TRM GROUP / ERCTA 29

The physical layout and surroundings of the workplace can affect health and safety.
Injuries may be caused by sharp table edges. Hazardous or highly inflammable
fumes may be produced in areas where operatives work or where there are naked
lights. Or, the workplace may be organized in such a way that there is not enough
circulation space. Or, it may be impossible to see or hear warning signals, eg
during fork lift truck movements.
Employees should be able to see the whole of their work area and see what their
immediate colleagues are doing. The workplace should be organized in such a
way that safe practices are encouraged. In other words, workplace arrangements
should discourage employees from running risks, eg providing a clear walkway
around machinery will discourage people from crawling under or climbing over it.
14.) Did the nature or shape of the materials influence the adverse event?
As well as being intrinsically hazardous, materials can pose a hazard simply by their
design, weight, quality or packaging, eg heavy and awkward materials, materials
with sharp edges, splinters, poisonous chemicals etc.
The choice of materials also influences work processes, eg a particularly hazardous
material may be required. Poor quality may also result in materials or equipment
failing during normal processing, causing malfunctions and accidents.
15.) Did difficulties using the plant and equipment influence the adverse event?
Plant and equipment includes all the machinery, plant and tools used to organise
and carry out the work. All of these items should be designed to suit the people
using them. This is referred to as ergonomic design, where the focus is on the
individual as well as the work task the item is specifically designed to carry out. If the
equipment meets the needs of the individual user, it is more likely to be used as it is
intended - ie safely. Consider user instructions here. A machine that requires its
operator to follow a complicated user manual is a source of risk in itself.
16.) Was the safety equipment sufficient?
You should satisfy yourself that any safety equipment and safety procedures are
both sufficient and current for all conditions in which work takes place, including the
provision and use of any extra equipment needed for employees’ safety. For
example:
¾ extra technical safety equipment at machines;
¾ power supply isolation equipment and procedures;
¾ personal protective equipment (PPE);
¾ Building safety systems, eg an extract ventilation system.
Make a note of whether the safety equipment was used, whether it was used
correctly, whether or not it was in good condition and was working properly etc.
17.) Did other conditions influence the adverse event?

TRM GROUP / ERCTA 30

‘Other conditions’ is intended to cover everything else that has not been reported
yet, but which might have influenced the adverse event. For example:
¾ disagreements or misunderstandings between people;
¾ the weather;
¾ unauthorized interference in a process or job task;
¾ defective supplies or equipment;
¾ Deliberate acts, such as trespass or sabotage.
STEP TWO ANALYSING THE INFORMATION
An analysis involves examining all the facts, determining what happened and why.
All the detailed information gathered should be assembled and examined to
identify what information is relevant and what information is missing. The information
gathering and analysis are actually carried out side by side. As the analysis
progresses, further lines of enquiry requiring additional information will develop.
To be thorough and free from bias, the analysis must be carried out in a systematic
way, so all the possible causes and consequences of the adverse event are fully
considered. A number of formal methods have been developed to aid this
approach.
One useful method for organizing your information, identifying gaps and beginning
the analysis is Events and Causal Factor Analysis (ECFA), which is beyond the scope
of this guidance.
The analysis should be conducted with employee or trade union health and safety
representatives and other experts or specialists, as appropriate. This team approach
can often be highly productive in enabling all the relevant causal factors to
emerge.
There are many methods of analyzing the information gathered in an investigation
to find the immediate, underlying and root causes and it is for you to choose
whichever method suits you best.
18.) What were the immediate, underlying and root causes?
It is only by identifying all causes, and the root causes in particular, that you can
learn from past failures and prevent future repetitions. The causes of adverse events
often relate to one another in a complex way, sometimes only influencing events
and at other times having an overwhelming impact, due to their timing or the way
they interact. The analysis must consider all possible causes. Keep an open mind.
Do not reject a possible cause until you have given it serious consideration. The
emphasis is on a thorough, systematic and objective look at the evidence.
ANALYSIS
What happened and why?

TRM GROUP / ERCTA 31

The first step in understanding what happened and why is to organize the
information you have gathered. This guidance uses the simple technique of asking
‘Why’ over and over, until the answer is no longer meaningful. The starting point is
the ‘event’.
For each of the reasons identified ask ‘Why?’ and set down the answers. Continue
down the page asking ‘Why’ until the answers are no longer meaningful.
Do not be concerned at the number of times you ask the question, ‘Why?’ because
by doing so you will arrive at the real causes of the adverse event. Some lines of
enquiry will quickly end.
Having collected the relevant information and determined what happened and
why, you can now determine the causes of the adverse event systematically.
Checklist/question analysis of the causes
Using the adverse event analysis work sheets and checklist, work through the
questions about the possible immediate causes of the adverse event (the place,
the plant, the people and the process) and identify which are relevant.
Record all the immediate causes identified and the necessary risk control
measures.
For each immediate cause, the analysis suggests underlying causes which may
have allowed the immediate causes to exist.
Consider the underlying/root cause questions suggested by the immediate causes.
Record those that are relevant and note the measures needed to remedy them.
The final step of your analysis is to consider the environment in which the
organization and planning of health and safety was carried out.
What if ‘human failings (errors and violations) are identified as a contributory
factor?
If your investigation concludes that errors or violations contributed to the adverse
event, consider carefully how to handle this information.
Not addressing the ‘human’ factors greatly reduces the value of the investigation.
The objective of an investigation is to learn the lessons and to act to prevent
recurrences, through suitable risk control measures. You will not be able to do that
unless your workforce trusts you enough to co-operate with you.
Laying all the blame on one or more individuals is counter-productive and runs the
risk of alienating the workforce and undermining the safety culture, crucial to
creating and maintaining a safer working environment.
Speak to those involved and explain how you believe their action(s) contributed to
the adverse event. Invite them to explain why they did what they did. This may not
only help you better understand the reasons behind the immediate causes of the
adverse event, but may offer more pointers to the underlying causes: perhaps the
TRM GROUP / ERCTA 32
production deadline was short, and removing the guards saved valuable time;
maybe the workload is too great for one person etc.
Unless you discover a deliberate and malicious violation or sabotage of workplace
safety precautions, it may be counter-productive to take disciplinary action against
those involved. Will anyone be open and honest with you the next time an adverse
event occurs? What you should aim for is a fair and just system where people are
held to account for their behaviour, without being unduly blamed. In any event,
your regime of supervision and monitoring of performance should have detected
and corrected these unsafe behaviours.
Human failings can be divided into three broad types and the action needed to
prevent further failings will depend on which type of human failing is involved.
STEP THREE IDENTIFYING SUITABLE RISK CONTROL MEASURES
The methodical approach adopted in the analysis stage will enable failings and
possible solutions to be identified. These solutions need to be systematically
evaluated and only the optimum solution(s) should be considered for
implementation. If several risk control measures are identified, they should be
carefully prioritized as a risk control action plan, which sets out what needs to be
done, when and by whom. Assign responsibility for this to ensure the timetable for
implementation is monitored.
19.) What risk control measures are needed/recommended?
Your analysis of the adverse event will have identified a number of risk control
measures that either failed or that could have interrupted the chain of events
leading to the adverse event, if they had been in place. You should now draw up a
list of all the alternative measures to prevent this, or similar, adverse events.
Some of these measures will be more difficult to implement than others, but this
must not influence their listing as possible risk control measures. The time to consider
these limitations is later when choosing and prioritizing which measures to
implement.
Evaluate each of the possible risk control measures on the basis of their ability to
prevent recurrences and whether or not they can be successfully implemented.
In deciding which risk control measures to recommend and their priority, you should
choose measures in the following order, where possible:
¾ measures which eliminate the risk, eg use ‘inherently safe’ products, such as
a water-based product rather than a hydrocarbon-based solvent;
¾ measures which combat the risk at source, eg provision of guarding;
¾ Measures which minimize the risk by relying on human behavior, eg safe
working procedures, the use of personal protective equipment.
NB: In general terms, measures that rely on engineering risk control measures are
more reliable than those that rely on people.
TRM GROUP / ERCTA 33
20.) Do similar risks exist elsewhere? If so, what and where?
Having concluded your investigation of the adverse event, consider the wider
implications: could the same thing happen elsewhere in the organization, on this
site or at another location? What steps can be taken to avoid this?
Adverse events might not have occurred at other locations yet, but make an
evaluation as to whether the risks are the same and the same or similar risk control
measures are appropriate.
21.) Have similar adverse events happened before? Give details.
If there have been similar adverse events in the past why have they been allowed
to happen again? The fact that such adverse events are still occurring should be a
spur to ensure that action is taken quickly. You will be particularly open to criticism if
you as an organization ignore a series of similar accidents.
Remember that there is value in investigating near-misses and undesired
circumstances: it is often only a matter of luck that such incidents do not result in
serious injuries or loss of life.
STEP FOUR THE ACTION PLAN AND ITS IMPLEMENTATION
22.) Which risk control measures should be implemented in the short and long
term?
The risk control action plan
At this stage in the investigation, senior management, who have the authority to
make decisions and act on the recommendations of the investigation team,
should be involved.
An action plan for the implementation of additional risk control measures is the
desired outcome of a thorough investigation. The action plan should have SMART
objectives, ie Specific, Measurable, Agreed, and Realistic, with Timescales.
Deciding where to intervene requires a good knowledge of the organisation and
the way it carries out its work. For the risk control measures proposed to be SMART,
management, safety professionals, employees and their representatives should all
contribute to a constructive discussion on what should be in the action plan.
Not every risk control measure will be implemented, but the ones accorded the
highest priority should be implemented immediately. In deciding your priorities you
should be guided by the magnitude of the risk (‘risk’ is the likelihood and severity of
harm). Ask yourself ‘What is essential to securing the health and safety of the
workforce today?’ What cannot be left until another day? How high is the risk to
employees if this risk control measure is not implemented immediately? If the risk is
high, you should act immediately.

TRM GROUP / ERCTA 34

You will, no doubt, be subject to financial constraints, but failing to put in place
measures to control serious and imminent risks is totally unacceptable. You must
either reduce the risks to an acceptable level, or stop the work.
For those risks that are not high and immediate, the risk control measures should be
put into your action plan in order of priority. Each risk control measure should be
assigned a timescale and a person made responsible for its implementation.
It is crucial that a specific person, preferably a director, partner or senior manager,
is made responsible for ensuring that the action plan as a whole is put into effect.
This person doesn’t necessarily have to do the work him or herself but he or she
should monitor the progress of the risk control action plan.
Progress on the action plan should be regularly reviewed. Any significant departures
from the plan should be explained and risk control measure rescheduled, if
appropriate. Employees and their representatives should be kept fully informed of
the contents of the risk control action plan and progress with its implementation.
23.) Which risk assessments and safe working procedures need to be reviewed
and updated?
All relevant risk assessments and safe working procedures should be reviewed after
an adverse event. The findings of your investigation should indicate areas of your risk
assessments that need improving. It is important that you take a step back and ask
what the findings of the investigation tell you about your risk assessments in general.
Are they really suitable and sufficient?

UNIVERSAL SAFETY
TRM GROUP / ERCTA 35
Safety and/or health sign – a sign providing information or instruction about safety
or health at work by means of a signboard, a colour, an illuminated sign or acoustic
signal, a verbal communication or hand signal;
Signboard – a sign which provides information or instructions by a combination of
shape, colour and a symbol or pictogram which is rendered visible by lighting of
sufficient intensity. In practice many signboards may be accompanied by
supplementary text e.g. ‘Fire exit’ alongside the symbol of a moving person.
Signboards can be of the following types:
• prohibition sign - a sign prohibiting behaviour likely to increase or cause
danger (eg 'no access for unauthorised persons');
• warning sign - a sign giving warning of a hazard or danger (eg 'danger:
electricity');
• mandatory sign - a sign prescribing specific behaviour (eg 'eye
protection must be worn');
Emergency escape or first-aid sign - a sign giving information on emergency exits,
first-aid, or rescue facilities (eg 'emergency exit/escape route'.
Safety colour - a colour to which a specific meaning is assigned (eg yellow means
'be careful' or 'take precautions');
Symbol or pictogram - although some variation in detail is acceptable provided
the meaning is the same. They are for use on a signboard or illuminated sign (eg
the trefoil ionising radiation warning sign);
Illuminated sign - a sign made of transparent or translucent materials which is
illuminated from the inside or the rear to give the appearance of a luminous
surface (eg many emergency exit signs);
Acoustic signal - a sound signal which is transmitted without the use of a human or
artificial voice (eg fire alarm);
Verbal communication - a predetermined spoken message communicated by a
human or artificial voice;
Hand signal - a movement or position of the arms or hands giving a recognised
signal and guiding persons who are carrying out manoeuvres which are a hazard or
danger to people;
Safety signs and colour are useful tools to help protect the health and safety of
employees and workplace visitors.
Safety signs are used to:
• draw attention to health and safety hazards
• point out hazards that may not be obvious
• provide general information and directions
• remind employees where personal protective equipment must be worn
• show where emergency equipment is located
• indicate where certain actions are prohibited

SIGN CATEGORIES/TYPES

TRM GROUP / ERCTA 36

TRM GROUP / ERCTA 37
TRM GROUP / ERCTA 38