Workbook Online Foundation

i
NEUCOM LTD
www.neucom.eu.com
ON-LINE STUDY WORKBOOK

FOR THE
IIAI
www.iiai.org.uk
FOUNDATION CERTIFICATE
IN
INDUSTRIAL ACCIDENT INVESTIGATION
AND ANALYSIS
Copyright. Neucom Ltd 2010. All rights reserved.
ii
CONTENTS
SECTION ONE
INDUSTRIAL ACCIDENT INVESTIGATION:

THE DRIVERS
Injury and ill-health statistics
Common law duty of care
Moral obligation
Economics and finance
Insurance and the cost of accidents
Property damage and near-miss accidents
Health and safety offences
Legal provision for investigations
Trade Union safety representatives
Police investigations
Powers of inspectors
Management systems
4-5
Section summary
SECTION TWO
OTHER DUTIES TO INVESTIGATE

Exercise
SECTION THREE
ACCIDENT INVESTIGATION PROGRAMS

Exercise
SECTION FOUR
REPORTS, RECORDS AND INFORMATION

Reporting schemes
iii
Accident books
Reporting of Injuries, Diseases and Dangerous Occurrences

Regulations 1995 (as amended 2012)
Notification by the quickest practicable means
Notification as soon as practicable
Form F2508; Part G
Examples of Major Injuries, Dangerous Occurrences and Diseases
3-4
Civil claims
Negligence
4-5
Standard disclosure documents
Legal privilege
SECTION FIVE
ACCIDENTS: RATIOS AND THEORIES

Accident ratios
Heinrichs accident causation theory
Heinrichs dominos
Number 3: the critical domino
Birds accident causation model
SECTION SIX
PART 1
GENERAL PROCESSES AND PROCEDURES
Three phases of an investigation
Initial response
1-2
Preliminary information
First actions at the scene
iv
The investigation file
Forms of evidence
Evidence management
PART 2
AIDS TO GATHERING EVIDENCE
Three stages of an accident
The five Ms
What is the investigator trying to do?
6-7
Exercise
Summary
SECTION SEVEN
WITNESSES AND INTERVIEWING

An introduction to some key aspects
A note on the eye witness
Perception
Ability
Lying and Deception
PLANNING & PREPARATION

Why are we interviewing?
The order of interviews
The interview environment
Closed and Open questions
Free narrative
Active listening and Summarising
4-5
Probing and Directed questions
v
Closing the interview
Summary and Conclusion
5-6
Exercise
SECTION EIGHT
PART 1
ATTITUDE AND BEHAVIOUR:
An introduction to behavioural influences
Attitude and Behaviour
Behavioural influences
1-2
PART 1
HUMAN ERROR:
An introduction to three types of error
SRK
2-3
Types of errors and some of their characteristics
3-4
Summary
SECTION NINE
PLOTTING THE ACCIDENT SEQUENCE

and
PRELIMINARY ANALYSIS
Introduction
Plotting the sequence
Final Exercise
1.1
SECTION ONE

THE DRIVERS
Please go through the on-line presentation for this section first. Then go through
it again and install text in the places denoted below by bold hatched lines.
Injury and ill-health statistics

In England, Scotland and Wales during the 08/09 period...
............ workers died at work.
............ members of the general public were killed.
_____________________________________________________________________
_____________________________________________________________________
_________________________________________________________
Northern Ireland and the Republic of Ireland accounted for an additional .................
deaths between them; including .......... children.
Across the member states of the European Union during 2007...
20,000,000 workers had work-related health problems.
.....,000,000 had accidents at work; ................ of which were fatal.
World-wide, work related accidents and disease kill at least ....... people every minute.
Common Law Duty of Care.

The common law duty of care expects everyone (individuals, members of the public,
duty holders and Organisations alike) to take reasonable care to avoid injuring others.
The leading case we referred to was Donoghue v ........................................ (1932).
Moral Obligation
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
1.2
_____________________________________________________________________
_________________________________________________________________
Economics and Finance
A case study involving a construction project calculated the costs of its accidents as
being equivalent to .................. of the tender price.
A case study involving an oil platform calculated the costs of its accidents as being
equivalent to .................. of output potential.
A case study involving a transport company calculated the costs of its accidents as
being equivalent to .................. of profits.
A case study involving a hospital calculated the costs of its accidents as being
equivalent to .................. of annual running costs.
A case study involving a creamery calculated the costs of its accidents as being
equivalent to .................. of operating costs.
Insurance and the cost of accidents

Whilst it would be nice to think that insurance covers the costs of accidents, the above
studies concluded that for every 1 spent on insurance, there were losses of 8-36 that
were uninsured; in other words, a very high percentage of costs are hidden.
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_______________________________________________________
Property damage and near-miss accidents

The costs in the above studies included property damage; but, we must also consider
the costs associated with near-miss accidents, especially in view of their frequency.
According to Birds study, for every minor injury, there were .......... property damage
accidents and ............. near-miss accidents.
1.3
Health and Safety Offences
Moral reasons aside, we saw from tables HSO1/2 why the possibility of criminal
action following an accident can turn its investigations attention towards mitigation
or defence; indeed, some Organisations require their investigators to always have the
potential for criminal (and Civil) 1 action in mind.
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________
Legal provision for investigations

Section 2(3) of the HSWA places an absolute duty on employers with five or more
employees to prepare:
A Health and Safety Policy;

Organisation (i.e. job titles or names of those with responsibilities under the
policy); and
Arrangements (i.e. what will be done, when, where and how).
Arrangements cover things such as monitoring of the H&S preventive and protective
measures; which includes ............................................ .................................................
Trade Union Safety Representatives

Note; in workplaces where a relevant trade union is recognised, the functions of duly
appointed safety representatives include...
examining the causes of accidents.
_____________________________________________________________________
______________________________________________________________
We shall look at basic Civil Procedures shortly below.
1.4
Police Investigations
_____________________________________________________________________
_____________________________________________________________________
________________________________________________________________
Powers of Inspectors
Section 20 of the HSWA gives inspectors wide ranging powers. In particular, we
looked at his powers to conduct investigations and interview people.
From the outset of his investigation, an inspector must assume that ..... criminal
............................................. could ............................... .
He will also look for evidence that ........................................ remedial action has been
taken to ............................... .......................................... ............................................. .
_____________________________________________________________________
_________________________________________________________
As regards s.20 interviews (also known as ........................................ interviews);
It is an offence to refuse to answer an inspectors questions but, the resulting
statement ............................. be used in criminal proceedings against the person who
provided it.
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
________________________________________________________
Management Systems
All management systems contain a requirement for an investigative process of some
sort; for instance...
OHSAS 18001 requires Organisations to establish and maintain procedures for
defining responsibility and authority forthe handling and investigation of...
....................................................;
1.5
....................................................; and
.................................................... .
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
__________________________________________________________
Committed to continual improvement, Organisations that maintain such management
systems utilise the investigative process as part of the mechanism that achieves it.
SECTION SUMMARY
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
____________________________________________________________
NEXT
That concludes Section One. Please go through it again if you need to (you should go
through it at least twice). Otherwise, ensure that all relevant areas of your work-book
(i.e. those where bold dotted lines denote that you are required to install
missing text), have been completed and proceed to the section one revision quiz.
2.1
SECTION TWO
OTHER DUTIES TO INVESTIGATE

There is no presentation for this section
EXERCISE:
Other than those that have already been identified or mentioned in Section One, write
down (in the space below) the title and section or regulation number of either an Act
of Parliament or a Regulation that contains a requirement for a duty holder to conduct
an investigation.
Unless you already know, please feel free to ask amongst your friends or colleagues.
Alternatively, go to the Neucom home page, find the open zone reading area and take
a look under UK Regulations.
_____________________________________________________________________
_____________________________________________________________________
_________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_________________________________________________________
NEXT
That concludes Section Two. Once you have completed the exercise, please proceed
to Section Three (note, there is no presentation for section three).
3.1
SECTION THREE
ACCIDENT INVESTIGATION PROGRAMS

There is no presentation for this section
An accident investigation program comprises all of the relevant system/s elements

relating to, or associated with, accident investigations; which include things like..
A Policy statement (i.e. regarding the duty holders intention to investigate

accidents);
Organisation (i.e. who is responsible for what);
Arrangements (i.e. what is to be done, how, where and when); such as...
o Instructions and guidance for various personnel;
first actions at the scene.
forms to be used.
deadlines for form completion.
o The level of training required by various personnel;
o Reporting procedures;
Internal requirements.
External requirements (e.g. in England, RIDDOR).
o ...and so on.
Whilst you can no doubt think of others, it has been said that the most important
element of an accident investigation program relates to its reporting procedures; on
which note, please now proceed to the section three revision quiz.
4.1
SECTION FOUR
REPORTS, RECORDS AND INFORMATION

There is no presentation for this section. Please read through it and
then proceed to the on-line section four quiz.
Reporting Schemes
Earlier, we looked at accident investigation programs and the importance of reporting
procedures. In general, and depending on how people are able or instructed to report,
those procedures can be classified as schemes; of which there are three...
Open reporting schemes;
Confidential reporting schemes; and
Anonymous reporting schemes.
Whilst your employer may operate one or more of the above, we will concentrate here
on those that are termed open; typically, these are required by law.
Accident Books (Form B1510).

Required under Social Security law,
in workplaces employing 10 or more people.
Employees (or someone on their behalf) may
make the entry or report orally.
To comply with the Data Protection Act 1998,
personal details must not be visible to future
users.
Records must be kept for at least three years.
Many Organisations do not have accident books in their workplaces but, collect the
legally required information in some other way; the legally required information is...
The name, address and occupation of the injured person; or the person who is
completing the entry on their behalf.
The date and time of the accident and the place where it happened.
The cause and the nature of the injury.
4.2
Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995.
These Regulations (referred to as RIDDOR) require duty holders to notify and report
specified events within specified time limits to the relevant enforcing authority;
Employers must nominate a responsible person to notify and report.
It is an offence to fail to notify or report.
Records must be retained for at least three years.
Notification by the quickest practicable means.

The relevant authority must be notified by the quickest practicable means and a report
sent within 10 days when
There is a death of any person from an accident arising out of, or connected
with, work; or
There is a Dangerous Occurrence or Major Injury (see examples below); or
Someone who is not at work is injured by an accident connected with work

and is removed to hospital for treatment.
Notification as soon as practicable.

a). If a person is incapacitated at work and unable to do work that they might
reasonably be expected to do for more than seven consecutive days (excluding the day
of the injury); or
b). a registered medical practitioner notifies the responsible person that an employee
has a reportable disease (see examples below), a report is required...
As soon as practicable and within 15 days for a). and 10 days for b).
4.3
Form F2508; Part G.
Deaths, injuries and dangerous occurrences are reported on form F2508 (diseases on
form F2508A). Whilst most of the information required by the F2508 will be readily
available, it is not always possible to complete Part G until an investigation has been
conducted; Part G asks the person completing it to...
Give the name of any substance or machine involved.
Describe...
what happened in as much detail as possible;

the events leading up to the incident;
the part played by any people;
what the injured person was doing; and
what action has since been taken to prevent a similar incident.
Examples of Major Injuries, Dangerous Occurrences and Diseases.

The precise lists of reportable Major Injuries, Dangerous Occurrences and Diseases
are in Schedules 1, 2 & 3 respectively of RIDDOR; the following are examples...
Major Injuries
Fractures, other than to fingers, thumbs or toes.
Dislocation of shoulder, hip, knee or spine.
Chemical or hot metal burn to the eye or a penetrating eye injury.
An injury from an electric shock or burn that leads to unconsciousness; or

requires resuscitation; or admittance to hospital for more than 24 hours.
Dangerous Occurrences
Collapse or overturning of a lift, hoist, crane, mobile elevating work platform,

excavator or fork lift truck or the failure of any load-bearing parts of these.
Failures of closed vessels, boilers or associated pipe-work where the pressure

was other than atmospheric and the failure had the potential to cause death.
Plant or equipment contacts, or causes electrical discharge from, un-insulated

overhead power lines where voltages exceed 200v.
Complete or partial collapse of scaffolds over 5 metres high.
Reportable Diseases
Poisonings such as those caused by mercury or benzene.
4.4
Skin diseases such as occupational dermatitis.
Lung diseases such as occupational asthma and asbestosis.
Civil Claims
The Health and Safety at Work Act 1974, the Management of Health and Safety at
Work Regulations 1999 and RIDDOR, for example, form part of the criminal law.
Criminal charges are brought by the State or Crown against Persons or Organisations;
with possible outcomes being a fine and/or imprisonment.
However, when a party (the claimant) feels that an injury or loss they have suffered
was due to the fault of some other party (the defendant), they utilise the civil law.
Civil claims are brought by Persons or Organisations against other Persons or
Organisations; with possible outcomes being remedial or compensatory. The process
usually begins with the claimants solicitor issuing a letter of claim to the defendant
and a copy for their insurer. In order that the defendant can start to investigate and put
a value on the risk, the letter must set out a clear summary of the facts and indicate
the nature of the injury/illness and/or financial loss incurred.
Defendants must acknowledge letters of claim within 21 days of receiving them and
(via investigation) admit or deny liability within three months of the letter of claim
being acknowledged.
Note: most Organisations have departments and/or persons that deal specifically with
letters of claim. Employees and investigators who come across these (unless passed
internally for comment) should pass them immediately (complete with the envelope
they came in if possible) to the relevant persons or department.
Negligence
Whilst it is sometimes possible to make a civil claim based on a breach of statutory
duty, most are brought under negligence; defined in Blyth 2 as...
the omission to do something which a reasonable man, guided upon those
considerations which ordinarily regulate the conduct of human affairs, would do,
or doing something which a prudent and reasonable man would not do.
As such, and recalling our earlier definition from Donoghue also, negligence will be
proved if it can be shown that...
The defendant owed the claimant a duty of care;
Blyth v Birmingham Waterworks Co. (1856).
4.5
The defendants negligence breached that duty of care; and
That breach caused the injury, loss or damage.
Standard disclosure documents

To assist such cases, the Civil Procedure Rules 1998 identify a range of documents
that should be available as standard for disclosure between the parties; the general list
for workplace claims is considerable but includes...
Accident book entries and/or medical centre records.
Relevant reports produced by first aiders, foremen, supervisors or safety

representatives.
Any document that has to be produced by law in order to comply with the
requirements of a relevant Act of Parliament or Regulation.
Legal privilege
Legal privilege recognises the right of a party to...
Consult with their legal advisors to determine a legal position; and
Keep those discussions exempt from disclosure.
However, for legal privilege to apply to a particular document, the main reason for its
existence must be that it was prepared for the partys legal advisors.3
Note, therefore, that documents and records that have to be produced in compliance
with, for example, RIDDOR, Accident Books, risk assessments, training, equipment
maintenance and routine accident investigations will not be legally privileged.
NEXT
That concludes Section Four. Please now proceed to the section four revision quiz.
Waugh v British Railways Board (1979).
5.1
SECTION FIVE
ACCIDENTS: RATIOS & THEORIES

Please go through the on-line presentation for this section first. Then go through
it again and install text into the places denoted below by bold hatched lines.
Accident ratios
Major.
Minor.
Property.
............... ...............
Heinrich also found high numbers of ................ .................. accidents occurring.
..................
..................
.............. ................
Injury by chance
He also found that the circumstances in the near-miss accidents were .......... ................
as those in the ................... .......................... .
5.2
Heinrichs accident causation theory
Heinrichs theory sees an injury as being the end result of a series of ....................... or
............................................... ; since each was dependent on another, he likened the
sequence to a row of falling dominos.
Heinrichs dominos
.................................
.................................
.............................. ......... ........ ..............................
............................. ........................
............................. ........................
Dominos .......... to ............... depict the

accident sequence.
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
______________________________________________________________
5.3
_____________________________________________________________________
_____________________________________________________________________
_______________________________________________________
Heinrich saw the removal of domino 3 as being critical due to his findings that ........
% of accidents were caused by ........................... .............................. and 88% by
............................. ............. .
Birds incident causation model
.......................... ......................... ........ ................

.................................
.............................. .......................... ........ .............
............................... ............ ........... .......................
.............. ......... .................................... ..................
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________
5.4
Dominos .......... to ............... depict the

incident sequence.
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
______________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_______________________________________________________
Heinrichs theory and Birds subsequent model appear to present opposing views on
cause; however, for us, they are a reminder that....
People, alone, are sometimes the cause of accidents;
Management, alone, are sometimes the cause accidents; and
Sometimes, it is a mixture of both.
An objective and impartial investigation will discover which, regardless.
5.5
SUMMARY AND CONCLUSION
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
________________________________________________________
NEXT
That concludes Section Five. Please go through it again if you need to (you should go
through it at least twice). Otherwise, ensure that all relevant areas of your work-book
(i.e. those where bold dotted lines denote that you are required to install
missing text), have been completed and proceed to the section five revision quiz.
6.1
SECTION SIX
Part 1:
ACCIDENT INVESTIGATION:
GENERAL PROCESSES AND PROCEDURES
Instruction:
There is no on-line presentation for Part 1 of this section. Once you have read
through this first part, please proceed to the on-line presentation for this section
where we will work through Part 2.
In addition to complying with the specifics of any scope of work that might have been
provided by the person or department requesting the investigation, we must always
adhere to our employers general instructions, protocols, processes and procedures;
that said, the following will assist us in what ever form those instructions etc arise.

The prospect of some investigations can be daunting. However, it is possible to break
an investigation (and, for later, accident sequences) down into manageable chunks.

Instruction,
preliminary information
gathering and mobilising to
the scene.
First actions at the scene and

the investigation proper.
Analysis, reports and next

actions.
Initial response
The initial response to an accident should be documented as a procedure that has to be
followed by all personnel (i.e. those at, or local to, the scene, relevant others in the
Organisation and, of course, investigators).
In particular, for us, instructions requiring those already on site to take certain steps
and precautions to ensure the integrity of the scene whilst the investigator is on route
can be critical. Often, investigators arrive to find that witnesses have been allowed to
leave without contact information being taken; or, that rescue, recovery or
remediation work has left the scene no longer resembling the final point in time when
the accident occurred.
Work that is necessary, for instance, to make a particular operation, process, structure
or item of equipment safe can relegate scene preservation to a secondary concern.
6.2
When disturbance is unavoidable, those on site should make sketches or take
photographs that will inform the investigator as to the full extent of the disturbance
(i.e. inform him of how the scene looked immediately after the accident).
A scene that is as close as possible to the final point in time of the accident is the one
that usually assists the investigator most.
Our initial information will usually come to us via the person who is requesting the
investigation; the sort of things we may need to know are...
Is there any specific scope or instruction from them;
Who is the investigation for?
o The names of those who can assist and/or who may receive any
resulting information.
A general description of things as they are currently known;

What was going on?
Location and time of accident;
Name of primary contact and any parties with responsibilities for relevant
processes, employees, or equipment at the scene.
o The location of these parties and the means of contacting them.
o Their positions within the relevant Organisation/s.
Whether any clearance is needed locally to enter the scene;

o What directions, instructions or passes are required?
Is the scene currently safe to enter?

What risks might the investigator be exposed to and who will assess this and
any necessary controls?
Is any special briefing, equipment or Personal Protective Equipment (PPE)
required for the investigator?
What basic equipment is needed (e.g. torch, camera, pens/pencils, note pad,
paper, warning signs/notices, tape measure, cones, cordoning tape/rope)?
What action has been taken (or is underway) to prevent immediate recurrence
or reduce risk?
Whether anyone has already commenced an investigation or report?
What has happened so far as regards internal and external emergency
response?
Have injured parties been taken care of and/or removed to safety?
The names of any injured parties or witnesses and their current location?
Are the Police, HSE or Emergency Services at the scene?
Are any insurance or legal representatives involved or at the scene?
Is there any media interest or involvement?
Timescales (e.g. for interim reports or to complete the investigation).
6.3
First actions at the scene
These will be guided by the above instructions and information and, importantly, by
what the investigator learns or finds once he arrives.
Locating the primary contact should be the first priority. The investigator will want to
visit the scene at some time and should seek information regarding any disturbance to
it and/or actions taken to preserve or protect it. He will also need to know about what
was going on, who was in control of the relevant task, area or process and about any
injured parties, participants and witnesses. From this and other information obtained
during the meeting or briefing (many of the above questions might be answered by
this person and they may well be the one who has requested the investigation) with
the primary contact, the investigator should be able to plan and prioritise accordingly.
The investigation file

This is an accurate diary, record or log of everything you do. As well as allowing you
to account for your time and actions, it holds all gathered information in one place and
provides the main point of reference for reviews, reports and future needs.
Commencing the production of a file early on (and keeping it maintained and up to
date) is good practice. As soon as possible, incorporate a plan of the scene into it so
that the location of evidence, witnesses, buildings, plant etc can be referenced on it.
Other than as instructed, the file should be kept secure and not circulated or copied to
unauthorised parties.
Forms of evidence
In a very general sense, evidence will come in one of five forms...
Physical;
Electronic;
Photographic;
Documentary; and
Testimonial.
Testimonial evidence (coming by way of discussions or interviews with people) is

often the first to be gathered. In the work-place, this will be in written form and may
result in a statement that is signed by the person providing it.
As regards interviews themselves, we shall look at these in section seven.
6.4
Evidence management
Evidence sometimes has to be moved and/or retained by the investigator; if you move
a piece of potentially critical evidence...
Ensure that it is safe to do so;

Photograph, sketch and/or record it in its as found position and condition (in
a photograph, try to include something that will give an indication of size);
Make reference on your site plan to the place where it was before you moved
it; and, if applicable, the place where it might have been prior to the accident.
If you have to retain an item of evidence (assuming you are authorised to)...
Inform the person who is responsible for it in your Organisation;

Clearly mark or label it;
Give the mark or label a unique reference number in your file, along with;
o a description of what the item is;
o who it can be released to and any special instructions for these;
o where it came from;
o when you retained it, why and how;
o who owns or is responsible for it;
o its general condition at the time of retaining it;
o whether it was, or could have been, damaged during recovery; and
o about anything that you or others have done to it.
As regards storage requirements, think about...
The length of time you may need to store it;

Space;
The effects of internal and external environments and their occupants (e.g. rats);
How it might degrade;
Whether it might become dangerous or unstable; and
Security.
6.5
Part 2:
AIDS TO EVIDENCE GATHERING
Please go to the on-line presentation for this part. Go through the presentation and,
as soon as you are happy, complete the exercise below and any relevant areas here
in your work-book before going on to Section Seven. Note, there is no revision
quiz for this section.
Three stages of an accident
The pre- .................................. .............................

Pre-accident stage events and ..........................................
The accident .............................
The post- .................................. ................................

Post-accident stage ......................... and circumstances.
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
___________________________________________________________
6.6
The Five Ms
M.......... .
M.........................
M................. .
M..................................... .
M............................... .
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
___________________________________________________________
What is the investigator trying to do?

In a nutshell, the investigator is attempting to find out...
W.........
was involved (.................................... or ......................................)
either as a .............................................. or a ......................................... ?
W............ was going on?
W............ (i.e. .................., ......................... and .....................) did the

relevant things happen?
W............. (i.e. the location/s) did these things .........................?
H.......... were these things being done?
6.7
W........; for what ........................... or ................................ and/or on whose

instruction.
To complete an analysis of things, the investigator may also need to know;
Who should ......................................................................................................?
What..................................................................................................................?
W.......................................................................................................................?
............................................................................................................................?
............................................................................................................................?
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
_________________________________________
6.8
EXERCISE
As there will be much more information coming in during the course, please start
to install the information into any relevant areas of the forms that you use for these
purposes in-house.
Machine involved:
Drivers name:
Materials involved:
People involved:
Property damaged:
People injured and nature of injuries:
How and where treated:
Regarding the use of PPE or other safety devices (e.g. seat belts) at the time of
the accident:
6.9
SUMMARY
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________
NEXT
That concludes Section Six. Please be sure to complete the exercise and the relevant
areas of your work-book before going to Section Seven (there is no revision quiz).
7.1
SECTION SEVEN
WITNESSES AND INTERVIEWING

An introduction to some key aspects
Please read down to probing and directed questions and then proceed to the online presentation.
A note on the eye witness

Be aware that witnesses who have apparently viewed the same events can produce
markedly different accounts of them; especially in relation to things like speed, shape,
colour, size, time and distance.
Perception
Generally, we classify what we see as either object or background. Backgrounds
are essentially formless and help us to judge the location of objects that we see in
front of them; however, we occasionally receive mixed cues about which is which.
Faces or vase?
Ability
Apart from the obvious stresses that a witness could be under, we must remain alert
to the possibility of other disadvantages.
According to the definition of disability under the Disability Discrimination Act 1995,
one in five of us has impaired
Sensory capability; and/or
Mental agility and cognitive function; and/or
Mobility.
....any of which could affect or limit what we were able to see or hear; or, as regards
the first two points, our ability to answer certain questions or recall things.
7.2
Lying and Deception
There is nothing extraordinary about lying, we start from about age three and continue
on a regular basis as we get older (we also spend quite a bit of time wondering if
things we have been told are true or not).
Of course, not all lying is malicious; sometimes, we can justify a little white lie. In
such cases, it easy to conceal the lie and we tend to get away it; however, things are
not quite so easy when the stakes are high.
Consciously lying in these cases is so emotionally and cognitively taxing for most of
us that there is a risk of displaying the associated signs of...
Guilt;
Fear;
Excitement;
Shame.
When these emotions are out of control and in hand with a lie, they can cause us to...
Seem less convincing; or uncertain, hesitant, tense or preoccupied;
Delay our responses;
Increase the pitch of our voice and the number of speech errors;
Repeat words or phrases;
Provide briefer responses. 4
Of course, some interviewees might just be nervous; so, be careful with the above. At
worst, all a lie means is that you will need to make further enquiries.
PLANNING AND PREPARATION
Interviewer Goal
Mutual Goal
Interviewee Goal
Extracts courtesy of Neucom Ltd from IIAI Advanced Interviewing Techniques.
7.3
Why are we interviewing?
We first need to be clear about why we intend to interview a particular witness; how,
by whom, or why, were they identified to us; what part/s of the accident sequence
might they be able to tell us about; what could, or should, they know. Think about...
The purpose, aims and objectives of the interview.
Current evidence...what is known...gaps in evidence...what needs to be known.
What you need to know.
What your employer or others need to know.
Your instructions, scope or guidance.
Interviewers should familiarise themselves with all available information regarding
the accident. If not known, personnel should be sought who can advise on regulatory
and organisational requirements applying in the particular location as well as the
personnel, equipment and materials in use there and any special or unique features.
We also need to find out as much as possible about the person to be interviewed.
The order of interviews

If there are a number of witnesses, it will be necessary to decide who to interview
first; here, think about things like...
Their degree of involvement, or potential involvement, in the accident.
The possibility of stress or shock, the need for treatment and the recovery
times for any of these.
Where they work (i.e. locally or some way away), shift patterns, holidays.
Whether they are a member of the public or (for instance) a delivery driver
(i.e. someone who might have more pressing matters to attend to elsewhere).
Relationships with other witnesses.
Whether someone else needs to be present.
Disability or language issues.
Ideally, interviews should be conducted as soon after the event as possible; however,
this is not always possible or practicable. Where this is the case, ensure that you have
enough information about them to enable contact at a later stage.
7.4
The interview environment
Interviews are often conducted locally, at or near the scene. General consideration
should always be given to the following but some interviews require more than others;
as regards a particular location/environment, consider things like...
General accessibility.
How the witness will get there.
Likelihood of noises or distractions at the planned time.
Temperature, lighting, seating, tables, fixtures.
Aids that might be required such as sketches, diagrams or photos (it sometimes
helps to show a witness (and/or to get them to show you) where they were at a
certain time or in relation to a certain event).
The means of recording the interview.
Availability of welfare facilities and refreshments.
Closed and Open questions

Interviewees should first be engaged in general conversation aimed at putting them at
ease. Explain why the interview is necessary and that what they know could be vital.
Avoid the early use of closed questions i.e. those that require short or one word
answers; e.g. what colour is Jims fork lift truck?
Free narrative
We need to know what the interviewee knows and this is best achieved, initially, with
a well framed open question; i.e. invite them, at the appropriate time, to....
Tell you...; or
Explain to you...; or
Describe to you... (e.g. tell me about the load on the fork lift; or describe
Jims fork lift to me; or explain how you came to be in the area).
Active listening and summarising

Good interviewers are active listeners. Having asked a witness to tell you what they
know about a particular topic, it is important that you let them. If they stop or pause,
resist the temptation to speak; silence is golden and, given time, most will resume.
7.5
When the witness has provided their response or answer, summarise it back in order
to confirm or clarify your understanding. Summaries should entail para-phrasing; i.e.
repeat things back as they were said to you, dont introduce new words or meanings.
Probing and Directed Questions

Please now go to the Section Seven presentation; Probing and Directed questions.
When you are finished there, please return here to complete your reading. Note; there
is no revision quiz for Section Seven.
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_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
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Closing the Interview

Let the witness know that the closing stages are approaching and ask them if there is
anything else that they would like to tell you. Read their statement back and allow
corrections if necessary. Finally, the witness should sign the statement and initial any
changes that have been made to it (note, not all Organisations require witnesses to
sign statements that they provide).
Try not to rush things; if possible, spend a little time in general conversation. Let the
witness know that you and the Organisation are grateful and that you will try to keep
them informed. Let them know that you might need to speak to them again and ask
them to contact you immediately should anything else come to light.
SUMMARY AND CONCLUSION

Six people, stood in the same place, watching the same event, could easily produce six
totally different accounts of it.
Some of us find answering questions and recalling facts genuinely difficult.
7.6
If you suspect a lie, dont take it personally; make further enquiries and be guided by
the weight of evidence.
Plan properly and gather as much preliminary information as you can.
Think about the order and location of interviews.
Ask questions appropriately, then listen to the answers.
EXERCISE
Based on what you now know from the presentation, either amend the information
that you previously installed into page 6.8 above; or, ideally and if at all possible,
install what you can into the relevant areas of any forms that your Organisation uses
for such purposes (more information is coming later).
If you are making lots of changes, ask yourself why?
Did you make any assumptions?
Did you assume that the initial information given to you was correct?
Note: There is no revision quiz for this section.
8.1
SECTION EIGHT
Part 1:
ATTITUDE AND BEHAVIOUR:
An introduction to behavioural influences
Please go through the on-line presentation at the same time
as your work-book.
Attitude and Behaviour

A persons Attitude towards something is a reflection of their .................................
............. .......................... ............ ........................ .................................... ...... . We cant
........... an attitude, we can only .......... ................. ......... .
Behaviour, on the other hand, is ob.....................le.
.............................. = what we say or think we will do;
.............................. = what we actually do.
Behavioural influences
Ideally, we like to behave in accordance with our attitude; doing something that is
contrary to our personally held views and beliefs can make us feel uncomfortable.
Nonetheless, the many considerations that people have to make and the influences that
come to bear on them do, regularly, modify their behaviour. In both work and play,
most of us weigh up a number of things before deciding to behave in a particular way.
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
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_____________________________________________________________________
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8.2
ATTITUDE
TO THE
BEHAVIOUR
We weigh both attitude and

subjective norm before
behaving in a particular way
INTENTION
BEHAVIOUR
SUBJECTIVE
NORM
Adapted from Ajzen & Madden (1986).
Part 2:
HUMAN ERROR:
An introduction to three types of error
As well as people and circumstances being able to effect our behaviour, nature has its
ways too; we sometimes do what we do in complete error, totally unaware.
If you take your IIAI studies further, you will look at this subject (and the one above)
in progressively more detail. Here, at Foundation level, it is only necessary to get a
handle on the basics; so, lets start with an introductory look at the SRK framework. 5
SRK
The SRK framework identifies three types of mental behaviour that could be guiding
or controlling a particular task, depending on its nature; the three types are
Skill-based;
Rule-based; and
Knowledge-based.
Skill-based behaviour is well learnt and results from a high degree of practice;
responses are virtually automatic (e.g. skilled typists).
Rule-based behaviour arises when the situation is familiar and we recognise the need
for a known rule to be applied (e.g. we see a red traffic light, we stop).
5
Rasmussen (1979).
8.3
Knowledge-based behaviour arises when we have no skill or rule to apply and are
working things out as we go (e.g. when an unusual or unexpected problem arises).
Types of errors and some of their characteristics

Later work found that each type of mental behaviour produced its own particular type
of error (see the tables below). 6
SRK:
Type of mental
behaviour
GEMS:
Type of error
Error characteristics
Occur during routine activities.
Skill-based
behaviour
Skill-based errors
Error is due to the persons attention being on some

thing other than the task in hand. Distraction and preoccupation will cause this type of error.
Usually detected quite quickly by the person involved.
Rapid corrective action usually follows and so the
vast majority of these could be called near-misses.
Very importantly; this type of error is highly
predictable.
SRK:
Type of mental
behaviour
GEMS:
Type of error
Occur during problem solving activities; i.e. those

where a known or pre-determined response or course
of action is required.
Rule-based
behaviour
Rule-based errors
Attention is on the problem in hand. But, the wrong

course of action or response has been selected in
error. The course of action would normally be right,
but not on this particular occasion.
The individual is unaware of the error. Consequently,
unless the system detects it and alerts the individual,
it normally requires third party detection.
Very importantly; as with skill-based errors, this type
of error is also predictable.
GEMS. Reason (1990). The accompanying tables have been adapted from this. Note, Reason termed
certain errors as mistakes; for ease of basic study, we have termed all as errors.
8.4
SRK:
Type of mental
behaviour
GEMS:
Type of error
Following an emergency or unusual situation, this

error occurs during attempts to solve the problem.
Knowledgebased
behaviour
Knowledge-based
errors
Individual is working things out as they go.

Has to monitor the situation to see if what they are
doing is helping things.
Any error is very difficult to detect since they dont
really know what they are doing.
SUMMARY
Regardless of what a persons stated or declared attitude might be, there are many
things that can influence their behaviour.
We are all prone to error; sometimes the error is intentional, sometimes it isnt.
That concludes this section. Please ensure that relevant areas of your workbook have been completed and, if happy, proceed to the on-line quiz.
9.1
SECTION NINE
PLOTTING THE ACCIDENT SEQUENCE

and
PRELIMINARY ANALYSIS
This section commences here in your work-book. Read on until your are asked to
go to the on-line presentation. When the presentation ends, return here to complete
the final exercise.
Introduction
As evidence is gathered, a picture of the likely sequence of events will begin to
emerge. We will start to find out about who was involved, what they were doing,
where, at what time, the equipment and tools involved and so on. We will find out
about circumstances, environmental conditions, the position of things, their weights,
sizes and similar quantifiable data.
Plotting the sequence

To help keep track of it all, we need to start plotting the accident timeline and events
early (ideally, from the outset of the investigation), in a simple and concise way.
14:05
14:10
14:11
14:16
Paul, the person who interviewed Jane, has been continuing with the investigation and
has produced some charts; so lets go to the presentation and see what hes done.
15:15
20/10/07
08:00
21/10/07
14:05
22/10/07
14:10
14:11
14:16
14:25
23/10/07
9.2
FINAL EXERCISE
Paul has now provided additional information for you. Hopefully, you have been
updating your in-house forms as the information has been coming in; if you havent
already done so, please update them where you can now.
Whilst Paul has some experience as an investigator, he is a little nervous due to his
lack of experience around man holes and fork lifts; quite rightly, he has declared this
to you. Neucom obviously received a copy of his diagram and notes and we have
reproduced things here in a manner that will allow us to see what he intended to do
next. As Paul requested, we have left spaces for you to comment about what he has
done; please also feel free to make notes on what you would have done and/or on
what you will do next.
_______________________________________
Paul has done well. He made contact with all of the key witnesses early and would be
able to go back to any of them again if he needed to.
He didnt get everyones surname but he told us that was due to nerves.
His questions were brief and to the point. He listened when he needed to and we saw
evidence of him providing non-committal prompts during Janes interview. He also
stayed silent when necessary during Bobs interview.
He was aware that he posed a question incorrectly to Bob regarding the oil etc having
come from the fork lift.
His notes were concise and enabled him to construct the accident time line in
reasonable detail at this stage.
Based on his latest diagram, he considered the sort of questions that would need
answering in order to analyse the related system requirements for fork lifts and work
in man holes.
The questions he would have asked of the system are as follows:

Mr Smith had the damaged man hole cover down for replacement next year. I would
like to know how the timing for this was arrived at. Also, how was any requirement
relating to its strength and suitability determined and...when?
Jane has tripped on the damaged man hole cover twice. It is highly likely that others
have tripped on it but not reported this. With pedestrian routes and access and egress
in mind, I would like to see a sample of the workplace inspections that have been
carried out for this area.
From Bobs interview, drivers have concerns about certain man hole covers.
Mr Smith told me that, years ago, only hand trucks were used on site.
9.3
Are there other man hole covers that might not be able to stand the weight of a loaded
fork-lift? Perhaps all relevant man hole covers should be inspected in the mean time.
_____________________________________________________________________
_______________________________________________________________
I need to know whether a permit was required for the repair work in the man hole. If
so, would it have prevented the man from forgetting about the bung. Also, should
anyone have inspected his work before declaring the job to be completed?
_____________________________________________________________________
_____________________________________________________________________
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Mr Smith attended the repaired man hole on his own to remove the bung. The man
hole is two metres deep. I would like to know what the policy is for confined spaces
and lone working.
As regards fork lifts:

During my initial enquiries, I heard that Jim had been disciplined in the past for not
wearing his seat belt. At present, it is possible that Bob was not wearing his at the
time of the accident. Pending the findings of the full investigation, the underlying
reasons for these failures should be assessed and addressed.
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I also heard that the tyres on the fork lift in question were due for replacement. Whilst
I do not see them as a causative factor (the man hole could easily have failed (and was
probably was about to) due to the weight of a fully loaded fork lift regardless of its
tyres), critical maintenance has been missed due to a supplier.
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9.4
At the accident scene, I found six empty boxes. Combined height stacked would be
approximately three metres. Individual weight approximately 18kgs. These had not
been secured to the fork lift. The underlying reason for this failure to secure a load
should be addressed along with seat belt use.
There could have been additional injuries since one of the boxes narrowly missed Jane
when it fell.
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Even though I have no experience of fork lifts and man holes, I am learning that all I
need to do is think about the controls that were, or should have been, in place to
prevent or minimise the injury or damage. In short, if the system was followed, would
the damage or injury have occurred?...and then, report or recommend accordingly.
_____________________________________________________________________
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______________________________________________________________
That concludes your course. Please keep your completed work-book safe in
case you take your IIAI studies further.
If you have filled in all of the areas in your work-book that require text to be
installed and, have completed all of the revision quizzes, you may now
proceed to the final exam.
Everything you need to pass it should now be in your work-book so, best of
luck and hope to see you on the IIAI members roll soon.

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ON-LINE STUDY WORKBOOK

Copyright. Neucom Ltd 2010. All rights reserved.

INDUSTRIAL ACCIDENT INVESTIGATION:

Common law duty of care

Economics and finance

Insurance and the cost of accidents

Property damage and near-miss accidents

Health and safety offences

Legal provision for investigations

Trade Union safety representatives

OTHER DUTIES TO INVESTIGATE

ACCIDENT INVESTIGATION PROGRAMS

REPORTS, RECORDS AND INFORMATION

Copyright. Neucom Ltd 2010. All rights reserved.

Reporting of Injuries, Diseases and Dangerous Occurrences

Notification by the quickest practicable means

Notification as soon as practicable

Form F2508; Part G

Examples of Major Injuries, Dangerous Occurrences and Diseases

Standard disclosure documents

ACCIDENTS: RATIOS AND THEORIES

Heinrichs accident causation theory

Number 3: the critical domino

Birds accident causation model

Number 1: the critical domino

First actions at the scene

Copyright. Neucom Ltd 2010. All rights reserved.

What is the investigator trying to do?

WITNESSES AND INTERVIEWING

Lying and Deception

PLANNING & PREPARATION

The order of interviews

The interview environment

Closed and Open questions

Active listening and Summarising

Probing and Directed questions

Copyright. Neucom Ltd 2010. All rights reserved.

Summary and Conclusion

Types of errors and some of their characteristics

PLOTTING THE ACCIDENT SEQUENCE

Plotting the sequence

Copyright. Neucom Ltd 2010. All rights reserved.

INDUSTRIAL ACCIDENT INVESTIGATION:

Injury and ill-health statistics

............ workers died at work.

............ members of the general public were killed.

20,000,000 workers had work-related health problems.

.....,000,000 had accidents at work; ................ of which were fatal.

Common Law Duty of Care.

Insurance and the cost of accidents

Property damage and near-miss accidents

Copyright. Neucom Ltd 2010. All rights reserved.

Legal provision for investigations

A Health and Safety Policy;

Trade Union Safety Representatives

examining the causes of accidents.

We shall look at basic Civil Procedures shortly below.

Copyright. Neucom Ltd 2010. All rights reserved.

Copyright. Neucom Ltd 2010. All rights reserved.

Copyright. Neucom Ltd 2010. All rights reserved.

OTHER DUTIES TO INVESTIGATE

Copyright. Neucom Ltd 2010. All rights reserved.

ACCIDENT INVESTIGATION PROGRAMS