NEBOSH Incident Investigation Workbook

INTRODUCTION TO
INCIDENT INVESTIGATION
A course book for the NEBOSH HSE
Introduction to Incident Investigation
Contents
Foreword 1
Element 1 Introduction to incident investigation 3
1.1 Incident terminology, arguments for investigations and management system
ELEMENT 1.1
requirements 3
Key terminology 4
Types of injury 5
Near misses 5
Dangerous occurrences 6
Why do we investigate incidents? 6
Moral, legal and financial arguments for investigations 7
Management system requirements (ISO 45001) 12
ELEMENT 1. 2
Benefits of incident investigation 15
Investigating near misses 16
References 17
1.2 Human and organisational factors 19

How human and organisation factors can contribute to an incident 12
References 25
ELEMENT 1. 3
1.3 The process for investigating incidents 27
What should be investigated 28
What does a good investigation look like? 28
Incident investigation teams 29
Deciding to investigate and the level of the investigation 30
Pre-investigation actions 32
The four-stage investigation process 32
References 41
ELEMENT 1. 4
1.4 Positive interview strategies and barriers to successful interviews 43
Reasons for carrying out prompt interviews 44
The PEACE model for interviewing 44
Barriers to good interviews 49
Reluctant or unwilling interviewees 48
Blame culture 50
Bias 51
Fundamental attribution error 54
ELEMENT 1. 5
1.5 Introduction to advanced incident investigation techniques 57

Root cause analysis: advanced incident investigation techniques 58
‘5 Whys’ technique 58
Fault tree analysis 60
Event tree analysis 61
Cause and effect analysis/fishbone diagram 61
Contents
Foreword
ELEMENT 1.1
ELEMENT 1.2
ELEMENT 1.3
The International Labour Organization (ILO) estimates that each year there are more than 2.78 million deaths worldwide as a
result of workplace incidents or work-related diseases. In addition to this it also estimates that there are 374 million non-fatal
work-related injuries and illnesses per year. The harm caused to individuals and the financial cost to organisations due to injury
and ill health is immense.
ELEMENT 1.4
The health and safety regulator for Great Britain, the Health and Safety Executive (HSE), estimates that annually there are
approximately 31 million working days lost, and the cost to the British economy of workplace injuries and ill health is around
£15 billion per annum.
It is, therefore, extremely important that organisations learn lessons from workplace incidents. The ultimate aim of an incident
investigation is to prevent recurrence of the same incident or, indeed, a more serious incident happening in the future.
Some compliance obligations (eg, the health and safety management system ISO 45001) also state that incidents must be
investigated and actions taken to prevent the incident from happening again.
ELEMENT 1.5
However, over time, HSE Inspectors from the British regulator have observed that incident investigation, in some organisations,
is not always carried out to the highest standard. This NEBOSH HSE Introduction to Incident Investigation qualification aims
to equip students with the knowledge, understanding and skills to carry out a solo investigation of a non-complex workplace
incident; students will also be able to contribute to team incident investigations for large-scale incidents.
Foreword 1
A guide to the symbols used in this course book
KEY TERMS
Definitions of key terminology.
ELEMENT 1.1
TOPIC 1
FURTHER INFORMATION
Information that is relevant to the topic being discussed that students may like to read/know. This information
helps to illustrate the topic being discussed.
i
ELEMENT 1.2
CASE STUDY
Real scenarios that give context to points made in the text.
ELEMENT 1.3
ACTIVITY
Carry out an activity to reinforce what you have just learned.
ELEMENT 1.4
THOUGHT PROVOKER
Thought provokers are used to get you to think about what you have learned and relate it to your own
experience.
ELEMENT 1.5
ASSESSMENT
At this stage students will need to undertake their assessment. Please refer to the INV ‘Guidance and
information for students and internal assessors’ document for further information. This document can be
downloaded from the NEBOSH website www.nebosh.org.uk.
Foreword
2
1.1
Incident terminology, arguments for investigations and

management system requirements
ELEMENT 1.1
ELEMENT 1.2
ELEMENT 1.3
This chapter will introduce students to some key terminology used in incident investigation via the ‘key terms’ box. It will also
look at the types of injuries likely to be encountered in the workplace. The chapter then goes on to explore the moral, legal and
financial reasons for investigating incidents along with health and safety management system requirements for investigating
incidents. It also looks at why monitoring and acting on near-miss data is important within an organisation. The final part of the
chapter will look at why it is important to co-operate with regulators and the role of insurers in incident investigations.
ELEMENT 1.4
Learning outcome
yy Understand incident terminology, the moral, legal and financial arguments for investigations and management system
requirements.
ELEMENT 1.5
NEBOSH HSE Introduction to Incident Investigation 3

1.1
Key terminology
KEY TERMS
Accident
ELEMENT 1.1
An adverse event that results in injury or ill health.
Incident
Occurrence arising out of, or in the course of, work that could or does result in injury and ill health. An incident where
injury and ill health occurs is sometimes referred to as an ‘accident’.
Dangerous occurrence
One of several specific, reportable adverse events as defined in the Reporting of Injuries, Diseases and Dangerous
ELEMENT 1.2
Occurrences Regulations 2013 (RIDDOR).
As detailed in HSG245: ‘Investigating accidents and incidents’
ACTIVITY
Think about the impact an injury and time off work would have on you, your colleagues, your work activities
and family. Note down what could be affected by your incapacity.
ELEMENT 1.3
ELEMENT 1.4
ELEMENT 1.5
NEBOSH HSE Introduction to Incident Investigation

4
1.1
Types of injury
KEY TERMS
Near miss
ELEMENT 1.1
An event not causing harm, but has the potential to cause injury or ill health.
http://www.hse.gov.uk/toolbox/managing/accidents.htm
Major injuries are those that could cause you lasting and debilitating harm, including:
yy head trauma;
yy resulting injuries from falls from height;
ELEMENT 1.2
yy broken bones, including bones that are chipped or fractured;
yy full dislocations of joints such as hip, shoulder, knee, spine or elbow; and
yy blunt or penetrating trauma.
Minor injuries that may require some first-aid attention would include:
yy cuts;
ELEMENT 1.3
yy skin or eye irritation from contact with a substance;
yy persistent cough;
yy burns that do not require skin grafting/surgery;
yy sprains and strains, or ligament damage;
yy whiplash-type injuries; and
ELEMENT 1.4
yy partial dislocations of joints such as shoulder, knee or elbow.
Near misses
As we can see from the key terms, near misses are incidents where no injury/harm has occurred. Even though near misses
are not normally reportable under local legislation, it is still important to record them.
Examples of near misses (where no injury or harm was caused) include:
yy tripping over a trailing cable;

ELEMENT 1.5
yy falling down a step;
yy an unattended ladder slipping down a wall due to lack of securing; and
yy falling over uneven ground.

1.1
Dangerous occurrences
Dangerous occurrences under UK legislation include:
yy a collapse or partial collapse of a scaffold over five metres tall;

ELEMENT 1.1
yy an overturn of any load-bearing part of lifting equipment;
yy contact with overhead power lines;
yy fire or explosion that closes a premises for more than 24 hours; and
yy accidental release of a flammable substance of certain quantities.
These types of dangerous occurrences are often reportable under country-specific legislation, eg RIDDOR in the UK. Other parts
of the world may have similar regulations. However, you should bear in mind that this book is looking at minimal/low-level
ELEMENT 1.2
investigations so it is very unlikely that you would be carrying out an investigation of one of these ‘reportable’ examples. You
are more likely to carry out investigations where minor or no injuries have occurred. Examples of these might be:
yy a fall from a step-ladder causing a sprained ankle; or
yy a hammer falling off a shelf and hitting someone on the arm causing bruising.
There are also workplace diseases that are reportable, such as carpal tunnel syndrome and occupational asthma, as well as
other diseases such as leptospirosis or Legionnaires’ disease.
ELEMENT 1.3
Why do we investigate incidents?

ELEMENT 1.4
ELEMENT 1.5
The primary reason for investigating accidents and incidents is to identify the contributory causes to prevent recurrence. If
the incident is reportable within the country’s legal framework, we would have to ensure that relevant information surrounding
the circumstances of the incident is gathered to pass on to the relevant regulatory authority. The same would apply for the
organisation’s insurance company if there was a chance for injured parties to seek compensation for the harm caused to them,
or potentially claiming on company insurance directly for damage to equipment or property.

6
1.1
Moral, legal and financial arguments for investigations
The legal argument

Although incident investigation is not explicit in legislation,
organisations in many countries will have a legal obligation to
ELEMENT 1.1
carry out ‘suitable and sufficient’ risk assessment. In the UK,
this duty falls under the Management of Health and Safety
at Work Regulations. An incident that goes un-investigated
would potentially show that the risk assessment for that
work activity was not suitable and sufficient. However, even
where there is no legal duty to investigate or carry out a risk
assessment, it is still good practice to do so.
The penalties in terms of fines and imprisonment apply to
ELEMENT 1.2
both individuals and organisations who do not operate within
the law. Investigating effectively can demonstrate to the courts that you are taking steps to ensure a similar event cannot occur
again.
There are differing standards of health and safety around the world. However, organisations that cause harm to workers may
have to fully disclose the circumstances surrounding an incident, especially where enforcement agencies/injured parties are
looking to take legal action or seek compensation.
As mentioned earlier, certain categories of injury or incident are legally reportable. In the UK, this falls under RIDDOR.
ELEMENT 1.3
Categories of injury or incident that are usually reportable are:
yy fatalities;
yy specified injuries;
yy injuries causing more than seven days' absence from work/normal working duties;
yy occupational diseases; and
ELEMENT 1.4
yy dangerous occurrences.
Where the regulators are involved in the incident

investigation, the regulator will normally be responsible for
giving the all-clear for the incident site to be restored to its
normal condition. In the UK, in the case of a fatality, it will
be the police who must give the all-clear for the site to be
restored to its original condition. When an incident occurs:
ELEMENT 1.5
yy organisations must take steps to ensure that the

evidence and scene are not disturbed until permission is
given by the relevant authority;
Fire resulting in the stoppage of production for more than 24 yy the internal investigation may continue alongside any
hours is classed as a dangerous occurrence in the UK external enquiry.

1.1
It is important for organisations to co-operate fully with external regulators/enforcement agencies when incidents are being
investigated. Co-operation may be seen as a mitigating factor by judges when sentencing; this could lead to a lower level
of fine/penalty if the organisation is found guilty of an offence. If the regulator intends to prosecute, they will inform the
dutyholder as soon as there is enough evidence to support a prosecution.
i
ELEMENT 1.1
FURTHER INFORMATION
The Reporting of Injuries, Diseases and Dangerous Occurrence Regulations 20131 cover England, Scotland
and Wales. Northern Ireland has its own set of regulations, the Reporting of Injuries, Diseases and Dangerous
Occurrence Regulations (Northern Ireland) 1997.2 The regulations put duties on employers, including self-employed
people or the responsible person for a work premises, to report certain serious incidents, occupational diseases and
dangerous occurrences. Each of these categories is discussed later in this book.
In England, Scotland and Wales, these incidents are reported to the British Health and Safety Executive (HSE). Incidents
ELEMENT 1.2
in Northern Ireland are reportable to the HSENI. Other parts of the world may have similar regulations. As a best practice
guidance, the International Labour Organization has produced a ‘best practice’ Code of Practice, ‘Recording and
notification of occupational accident and diseases',3 which provides guidance and information to those people who may
be engaged in setting up systems, procedures and arrangements.
Students who are located outside of the UK are advised to make themselves familiar with any local legislation which is
relevant to their place of work.
ELEMENT 1.3
CASE STUDY
As stated earlier in this book, organisations located in the UK are subject to RIDDOR legislation. Failure to
report an incident can result in prosecution. For example, in 2015 a contractor was digging out a basement of
a house. Cracks appeared in the structure so the contractor contacted a structural engineer for advice; advice which he
subsequently ignored. This resulted in the ground floor of the house collapsing into the basement. The contractor failed
to report this as a dangerous occurrence.
The HSE subsequently prosecuted the contractor under RIDDOR and other health and safety legislation. The contractor
ELEMENT 1.4
was found guilty and received a prison sentence of two months, which ran concurrently with a sentence of five months
that he received for another health and safety offence. The contractor was also ordered to pay costs of £7000.4
ELEMENT 1.5

8
1.1
ACTIVITY
Why is it so important not to give information to third parties?
ELEMENT 1.1
ELEMENT 1.2
ELEMENT 1.3
Some of the reasons for not disclosing evidence include:
yy any disclosure of evidence or liability could potentially interfere with the impartiality of any prosecution;
ELEMENT 1.4
yy it could lead to misrepresentation of the circumstances being reported in the press; and
yy public opinion can have a detrimental effect on an organisation’s reputation. ELEMENT 1.5

1.1
The moral argument

ELEMENT 1.1
ELEMENT 1.2
ELEMENT 1.3
Nobody goes to work wanting to get hurt or injured and, hopefully, nobody goes to work wanting to harm others. When
ELEMENT 1.4
someone suffers an injury at work, the effects of that incident or harm can extend to many others: the injured party’s family,
colleagues and others who witnessed the incident.
The moral argument for investigating incidents stems from our duty of care, not just to colleagues but to any others who may
get hurt. It is unacceptable for workers to suffer harm that is caused or made worse by their work activities.
yy Valuable lessons can be learned from investigating incidents to improve safety, especially their underlying and root causes.
yy Investigating incidents can assist in identifying deficiencies in the management of an organisation’s risk.
ELEMENT 1.5
yy An effective investigation can give organisations a true picture of what really happens and how work is really carried out.
The absence of an incident doesn’t always equal the presence of safety. An organisation can think it is safe due to a lack of
reported incidents, but it might have just been very lucky, or it may have a poor safety culture which results in incidents and
near misses going unreported.

10
1.1
The financial argument
ELEMENT 1.1
ELEMENT 1.2
ELEMENT 1.3
Incidents cost money, and not just to organisations (as mentioned under the legal argument), but to individuals also. An injury
and time off work could result in the injured person’s salary being reduced, or potentially they may only be entitled to statutory/
basic sick pay from the state. Either way, the injured person’s income may be severely affected, which may result in unpaid
household bills. This in itself could lead to depression or other mental ill-health conditions resulting in further time off work.
It should also be borne in mind that insurance claims can take a lengthy time to be concluded, and injured parties may have to
survive with little to no income during that time.
ELEMENT 1.4
Finding out the cost of an accident can be a good argument for better safety measures within an organisation. Typically,
some of the costs likely to be borne by the organisation include sick pay, replacement staff costs, costs for replacing damaged
machinery and/or stock, lost time and production costs, etc. Further information on the costs to the organisation is included
later in this book under ‘The role of insurers in incident investigation’.
ELEMENT 1.5

1.1
Management system requirements (ISO 45001)

The international standard ISO 45001 identifies an incident
as a non-conformity within the organisation. The standard
requires organisations to have processes in place, which
ELEMENT 1.1
include incident investigations to manage incidents.
When an incident (non-conformity) occurs, the standard

requires that organisations must:
yy Try to prevent recurrence through worker involvement

and with other relevant parties’ input by:
–– investigating the incident;

Non-conformance
ELEMENT 1.2
–– finding the cause(s) of the incident;

–– reviewing any existing risk assessments;
–– deciding what actions are needed to stop a recurrence (application of the hierarchy of control (see later) will assist with
this step); and
–– reviewing how effective any additional controls/actions have been.
Leading and lagging indicators of health and safety performance

It is a requirement of the ISO 45001 standard to measure health and safety performance: incident investigation is therefore a
ELEMENT 1.3
pivotal part of that requirement.
Lagging indicators give the organisation’s management information about previous actions. Some examples of lagging
indicators are:
yy injury frequency and severity;
yy fatalities;
yy lost-time incidents;
ELEMENT 1.4
yy reportable incidents; and
yy worker claims and compensation costs.
Lagging indicators are not enough to give us a full view of an organisation’s health and safety performance as they only
measure after an event has occurred.
Leading indicators look at how our current health and safety performance could be affected by future events, and provide a
potential insight into the future. Some examples of leading indicators include:
ELEMENT 1.5
yy number of health and safety training sessions carried out;
yy hazard spotting and reporting;
yy safety articles, eg HSE bulletins or OSHA news releases;
yy initiatives to improve safety culture;
yy positive feedback and recognition for health and safety performance;

12
1.1
yy risk assessment, management and control;
yy safety culture surveys among the workforce;
yy safety audits and inspections; and
ELEMENT 1.1
yy communication, participation and consultation of workers in a safety system.
The role of insurers in incident investigation
ELEMENT 1.2
ELEMENT 1.3
Many countries have legal requirements for organisations to have appropriate levels of insurance in place. For example, in the
UK, this is covered under the Employers’ Liability (Compulsory Insurance) Act 1969. Regular claims on insurance after incidents
will undoubtedly result in insurance premiums rising, along with excesses to be paid by the organisation towards any claim.
ELEMENT 1.4
yy Organisations must investigate with the correct level of depth to ensure the insurance company has the necessary facts for
any compensation claims that may arise because of the incident.
yy Organisations may be refused insurance in certain areas if they

are unable to demonstrate that the process or activity is being
managed effectively.
yy Insurers (along with shareholders, etc) will want assurance

ELEMENT 1.5
that proper controls are in place to prevent similar events.
There are some costs that can be recovered from insurance but
there are many that cannot. It is estimated that the ratio of
insured versus uninsured costs is roughly 1:8. So for every £1
of costs recovered from insurance, an organisation will pay out
unrecoverable costs of about £8 but this could be as high as £36. Hidden costs of incidents

1.1
ACTIVITY
Think about the costs of an accident to an organisation. How many of these would be recoverable?
ELEMENT 1.1
ELEMENT 1.2
ELEMENT 1.3
Examples of insured or recoverable costs of an incident are:
yy medical costs relating to injury and/or ill health; and

ELEMENT 1.4
yy damages to the injured party or to the family of a deceased worker.
Examples of uninsured costs of an incident are:
yy investigation time;
yy productivity/down-time during investigation;
yy retraining costs;
ELEMENT 1.5
yy increase in insurance premiums;
yy lost business through down-time and diminished reputation;
yy loss of expertise;
yy further control measures; and
yy low staff morale affecting productivity.

14
1.1
Benefits of incident investigation

Organisations that effectively investigate incidents within their work activities will glean a better understanding of how their
organisation works. It will also demonstrate to their workers (clients, prospective clients and shareholders) their commitment to
ensuring the health, safety and welfare of those affected by their work activities. Other benefits include:
ELEMENT 1.1
yy the prevention of further similar adverse events, which could potentially lead to a worse outcome;
yy the prevention of further business losses due to disruption, down-time, lost orders, the cost of prosecution and fines and a
rise in insurance premiums;
yy an improvement in worker morale and attitude towards safety; and
yy the development of managerial skills which can be applied to other areas of the organisation.
ELEMENT 1.2
CASE STUDY
Slippery store entrance in wet weather - supermarket entrance matting
The problem
In a recently opened supermarket, staff and members of the public experienced a number of slip, trip and falling
accidents. The areas of the supermarket that were most affected by a high slip risk when wet were the terrazzo floor tiles
in the entrance area and the first few aisles of the supermarket adjacent to this entrance.
ELEMENT 1.3
The solution
It was identified that the supermarket experienced a high level of water ingress from rain in the foyer. The entrance
matting systems in place were not large enough to cope with the amount of water transferred onto the mats from
pedestrian movement. The solutions were both long and short term. In the short term, the company increased the
frequency of cleaning in the foyer at times of wet weather. This frequency depended upon the number of people entering
the building and the amount of rain. A system was put in place so that the staff were constantly vigilant for signs of
water on the supermarket floor. When water was identified inside the store, cleaning would follow. The method of
cleaning used in these areas was also altered. Rather than mopping (which left the floor surface wet), staff used a wet
ELEMENT 1.4
vac, which left the floor dry.
The supermarket also reviewed the matting system. The existing sunken matting was complemented by extra matting
during wet conditions. In the longer term, the supermarket built a canopy over the entrance to further reduce the direct
ingress of water.
The cost
The cost for training staff regarding the frequency of cleaning was approximately half a day per member of staff and the
ELEMENT 1.5
wet vac cost less than £500. The supplementary entrance mats cost about £20 each. The cost of the additional canopy
was absorbed during store refurbishment, as a canopy was planned to be built before the store opened.
After 18 months of these changes being in place there had not been a serious slipping accident.
Source: HSE, case study section5

1.1
Investigating near misses

ELEMENT 1.1
ELEMENT 1.2
THOUGHT PROVOKER
We have now looked at the strong argument for investigating incidents, but why is it important to investigate
incidents that do not result in harm?
ELEMENT 1.3
Near-miss reporting and investigating can allow an organisation the opportunity to learn lessons and make changes to improve
safety before harm occurs.
Organisations that have an effective near-miss reporting and investigation

process are statistically proven to have fewer, and less severe, incidents.
Frank E. Bird analysed nearly 2 million accidents across over 250

organisations. These organisations were across a broad range of industries,
ELEMENT 1.4
which shows the figures work across all disciplines.
The 1:10:30:600 ratio, illustrated here, clearly demonstrates how short-

sighted it can be of an organisation not to take the opportunity to learn
lessons from near misses. We can, therefore, see from Bird’s Triangle that
organisations with any near misses are more likely to have serious incidents,
and are only measuring their health and safety performance by wrongdoing;
this may be perpetuated by a culture of not reporting incidents.
ELEMENT 1.5
Benefits of investigating near misses include:
yy an opportunity to rectify failings before harm occurs;
yy no injured parties to deal with; F.E. Bird’s Accident Ratio Triangle
yy witnesses more likely to be helpful and truthful; and
yy supporting the management system’s commitment of continual improvement.

16
1.1
References
1 Reporting accidents and incidents at work: A brief guide to the Reporting of Injuries, Diseases and Dangerous Occurrences
Regulations 2013 (RIDDOR), INDG453, HSE Books http://www.hse.gov.uk/pubns/indg453.pdf
ELEMENT 1.1
2 The Reporting of Injuries, Diseases and Dangerous Occurrences: Guidance on Regulations, HSENI https://www.hseni.gov.uk/
sites/hseni.gov.uk/files/publications/%5Bcurrent-domain%3Amachine-name%5D/riddor-guidance-on-regulations-hsa-31.pdf
3 International Labour Organization’s ‘Recording and notification of occupational accidents and diseases’ Code of Practice
https://www.ilo.org/safework/info/standards-and-instruments/codes/WCMS_107800/lang--en/index.htm
4 RIDDOR prosecution https://www.shponline.co.uk/in-court/builder-jailed-after-house-collapse/
ELEMENT 1.2
5 Benefits of investigating incidents case study: Slippery store entrance in wet weather - supermarket entrance matting
http://www.hse.gov.uk/slips/experience/store-entrance.htm
ELEMENT 1.3
ELEMENT 1.4
ELEMENT 1.5

1.1
Notes
ELEMENT 1.1
ELEMENT 1.2
ELEMENT 1.3
ELEMENT 1.4
ELEMENT 1.5

18
1.2
Human and organisational factors
ELEMENT 1.1
ELEMENT 1.2
ELEMENT 1.3
In this chapter, the role of human and organisational factors in incident investigation will be considered. It is important for
those undertaking investigations to understand what these factors are and how they can affect each other. The chapter will
then go on to discuss how conscious and unconscious actions of workers could contribute to incidents.
Learning outcome
yy Recognise how human and organisational factors can contribute to an incident.
ELEMENT 1.4
ELEMENT 1.5

1.2
How human and organisational factors can contribute to an incident
Human factors
KEY TERMS
ELEMENT 1.1
Human factors
Human factors refer to environmental, organisational and job factors, and human and individual
characteristics, which influence behaviour at work in a way which can affect health and safety.6
Human factors can be broken down into three individual groups:
yy job factors;
ELEMENT 1.2
yy individual factors; and
yy organisation and management factors.
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ELEMENT 1.3
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ELEMENT 1.4
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ELEMENT 1.5
Human factors
Based on HSG48: ‘Reducing error and influencing behaviour’7

20
1.2
Job factors
When looking at how job factors could contribute to an incident, some of the things to consider are:
yy poor design of equipment and instruments;
ELEMENT 1.1
yy interruptions and disturbances;
yy unclear or missing instructions;
yy poorly maintained or faulty equipment;
yy high demand/workload; and
yy unpleasant working environment, eg noisy, dirty, poor lighting, etc.
Individual factors
ELEMENT 1.2
It is estimated that over 80% of incidents can be attributed to the actions of people through their acts or omissions. It is,
therefore, really important that individual factors are taken into account; some of the things to consider are:
yy overworked, tired workers are more likely to have a lapse in concentration;
yy lack of competence in the work activity, or with a piece of equipment, can result in workers carrying out the work activity
unsafely or incorrectly using of a piece of equipment;
yy workers carrying out activities that are beyond their capability (either mentally or physically), eg, asking an overworked
ELEMENT 1.3
person to take on someone else’s workload or getting a physically underdeveloped youth to carry out lone heavy lifting
activities;
yy complacency: due to a lower perception of risk after a prolonged period of carrying out that work activity with no harm
resulting;
yy low morale/boredom; and
yy medical conditions/medication that causes drowsiness.
ELEMENT 1.4
ELEMENT 1.5

1.2
ELEMENT 1.1
ELEMENT 1.2
Low morale/boredom
Organisational factors
Many organisational factors can have an influence on the likelihood and severity of incidents.
ELEMENT 1.3
A lack of planning and suitable and sufficient risk assessment can end up with work activities being undertaken without a full
understanding of the level of risk involved with the work activity, the equipment or the environment.
This can also result in limited to no understanding of the competence level required for a worker to safely undertake a task, for
example:
yy lack of appropriate planning, resulting in excessive

pressures put on workers;
yy lack of a safe system of work in place prior to work

ELEMENT 1.4
starting;
yy inadequate resources allocated to work activities that can

result in the incorrect equipment being used for a task;
yy poor design of equipment or workplace layout, or poorly

maintained equipment;
yy lack of appropriate instructions, or unclear instructions that

can lead to workers making their own instructions up;
ELEMENT 1.5
yy poor safety culture - lack of incident reporting and/or poor Excessive pressure on worker
management commitment;
yy noisy or unpleasant working conditions that can result in workers struggling to concentrate due to the lack of comfort in
their work environment; and
yy unachievable targets due to time allocation or conflicting goals within the organisation, eg, “always work safely but remove
the guard from that machine so that we can complete this order more quickly”.8

22
1.2
Conscious and unconscious actions

People, for the most part, do not deliberately wish to cause
harm to themselves or others. There are many reasons why
a person chooses to act in a certain way, and they will often
be able to justify their behaviour by citing circumstances or
ELEMENT 1.1
perceived pressure.
When an individual makes a choice to behave in a certain

way, they are making a conscious decision. If they have a safe
method of working and are competent in this safe method,
deviating from this is known as committing a conscious act
(also known as a ‘violation’); this is a deliberate deviation
from a process or procedure.
ELEMENT 1.2
Conscious acts can be committed:
yy under exceptional circumstances - where something has

gone wrong and the worker is trying to make do with a
temporary fix; Routine conscious act - knowingly breaking the rules
yy in situational circumstances - where, due to a lack

of resources or insufficient time allocated for a task, ends with a worker making an unsafe choice due to the perceived
pressure upon them; and
ELEMENT 1.3
yy routinely - where breaking the rules or not following the intended process is regular and accepted practice. This can either
be due to a lack of management commitment to the process being conducted safely, or bad practices being passed down
through ‘on-the-job’ training.
Unconscious acts (also known as ‘errors’) are where a worker makes an unintended action or makes a decision with
unintended consequences based on the information available to them.
These acts are split between skill-based errors and mistakes.
ELEMENT 1.4
yy slips – an action not as planned;
yy lapses – such as forgetting to carry out an action, or

missing a step in a task;
yy rule-based mistakes – based on remembered rules and

applying the wrong rule; and
yy knowledge-based mistakes – misdiagnosis of a fault or

ELEMENT 1.5
miscalculating a measurement.
In each of these circumstances, an organisation can act to

reduce the chance of a worker being able to make these
choices, or create a safer work environment so that the worker is not left to make an unsafe choice.

1.2
FURTHER INFORMATION
Examples of unconscious acts:
i
Slip
ELEMENT 1.1
Two similar chemicals were manufactured at a chemical works in batch reactions. Each chemical required the presence of
an inorganic base to maintain alkalinity to prevent exothermic side reactions. When calculating the quantities of inorganic
base, a chemist inadvertently transposed the figures. As a result, one of the reactions only had 70% of the base. This,
resulted in an explosion which destroyed the plant.
Lapse
An experienced road tanker driver had virtually completed the filling of his vehicle from a bulk tank of flammable liquid
ELEMENT 1.2
when a nearby telephone rang. After ignoring it for some five minutes he closed the various valves on the installation
and went to answer it. On returning to the vehicle he drove away having forgotten that he had not disconnected the
tanker hose from the installation. Fixed pipework from the installation fractured and approximately one tonne of material
was lost.
Rule-based mistakes
An operator was very familiar with a tank filling process; he expected the process to take 30 minutes. However, he did
not know that the diameter of the pipe entering the tank had been enlarged, which meant that the tank will fill quicker.
ELEMENT 1.3
The operator ignored the high-level alarms because he knew that the tank could not fill so quickly. The tank overflowed.
Knowledge-based mistakes
A tunnel collapsed and the subsequent investigation found that the experience of one person had been relied on as a
control measure. However, the way the work was carried out meant that the person had no reliable instrumentation for
detecting when the tunnel was becoming unstable. Relying on ‘experience’ was actually relying on knowledge-based
reasoning.
Source: HSG48: ‘Reducing error and influencing behaviour’9

ELEMENT 1.4
ELEMENT 1.5

24
1.2
References
6 Definition of human factors, HSE http://www.hse.gov.uk/humanfactors/introduction.htm
7 Reducing error and influencing behaviour, HSG48, HSE Books http://www.hse.gov.uk/pUbns/priced/hsg48.pdf
ELEMENT 1.1
8 Core topic 2: HF in accident investigations, HSE http://www.hse.gov.uk/humanfactors/topics/core2.pdf
9 Reducing error and influencing behaviour, HSG48, HSE Books http://www.hse.gov.uk/pUbns/priced/hsg48.pdf
ELEMENT 1.2
ELEMENT 1.3
ELEMENT 1.4
ELEMENT 1.5

1.2
Notes
ELEMENT 1.1
ELEMENT 1.2
ELEMENT 1.3
ELEMENT 1.4
ELEMENT 1.5

26
1.3
The process for investigating incidents
ELEMENT 1.1
ELEMENT 1.2
This chapter deals with the incident investigation process; it starts by looking at what a good investigation looks like and why it
is important to learn lessons from incident investigations. The chapter then goes on to explore the investigation process. Levels
of investigation are discussed and then this chapter will delve into the four-step approach to investigation.
ELEMENT 1.3
Learning outcome
yy Outline the process for investigating incidents.
ELEMENT 1.4
ELEMENT 1.5

1.3
What should be investigated?

When deciding on what to investigate and the level of investigation, there are several things to consider:
yy the worst possible outcome of the incident;

ELEMENT 1.1
yy the likelihood of the incident happening again;
yy the lessons that can be learned and applied throughout

the organisation;
yy whether there has been a breach of legislation;
yy whether there are any civil liability implications;
yy if there is any uninsured risk(s); and

ELEMENT 1.2
yy whether the incident could have impacted on neighbours

or members of the public.
As discussed earlier in this book, some incidents are reportable under local jurisdiction legislation (in Great Britain this is under
RIDDOR).
What does a good investigation look like?

ELEMENT 1.3
KEY TERMS
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).
ELEMENT 1.4
Root causes
The failure from which all other failings grow (failure to identify training needs and assess competence, low priority given
to risk assessment, etc).10
Non-conformance in relation to incidents as detailed in the international standard ISO 45001: “Although there can be
one or more non-conformities related to an incident, an incident can also occur where there is no non-conformity.”
ELEMENT 1.5
Incidents can have one or more immediate causes, eg a worker tripping over a trailing electrical cable and wearing the wrong
footwear, but there will also be one or more underlying causes of why the accident occurred. In the case of the trailing cable,
underlying causes may relate to why the cable was left trailing there (sometimes known as the ‘unsafe condition’) and why
the worker did not see the cable and then tripped over it (sometimes known as the ‘unsafe act’).

28
1.3
The root cause or causes of the incident is often the management failure from which all other failures stem. In the simple
example we’ve just given, this may be due to there being no system in place to deal with trailing cables, which may be
a common situation throughout the workplace. Most, if not all, incidents can be prevented and the purpose of incident
investigation is to discover the immediate, underlying and root causes in order to take action to prevent a recurrence. The
results of the investigation, particularly the action plan, should be communicated to all concerned.
ELEMENT 1.1
Incident investigation teams
The size of the investigation team will depend on:
yy the size of the organisation; and
yy the complexity or seriousness of the incident.
ELEMENT 1.2
ACTIVITY
ELEMENT 1.3
Group discussion: Who would you typically involve in an investigation team for each level of investigation?
ELEMENT 1.4
ELEMENT 1.5

1.3
You will hopefully have identified the groups of people from the following table.
Deciding to investigate and the level of the investigation

The decision to investigate an incident must be based on both the likelihood AND the potential worst consequence of the
ELEMENT 1.1
incident. The following illustration shows the level of investigations in relation to both of these factors.
High
Medium High
ELEMENT 1.2
Likelihood Low Medium

ELEMENT 1.3
Minimal Low Medium
Low
ELEMENT 1.4
Low High
Consequence
ELEMENT 1.5

30
1.3
Level of investigation Criteria Who should be involved
Would be appropriate where the A supervisor looks at the incident and

incident is unlikely to happen again, circumstances and determines what
ELEMENT 1.1
and the worst consequence would be a needs to be put in place to prevent a
Minimal-level
minor injury. An example of this would similar event.
be a contact allergy to a worker while
using a substance for single use.
Would be carried out where the A supervisor or line manager does

incident could (certain, likely or a short investigation to identify
possible to) occur again but no injury immediate, underlying and root causes
ELEMENT 1.2
would result, such as dropping boxes to prevent it happening again.
Low-level during repetitive handling; or it would
be carried out where the incident is
unlikely to happen again but the injury
may be more significant, such as a trip
hazard in a non-routine one-off activity.
Would be appropriate where the This is a more detailed investigation
ELEMENT 1.3
incident is unlikely to happen again but that may involve safety representatives,
Medium-level could cause serious injury, such as a fall subject matter experts and the
from low-level height during a non- organisation’s health and safety team.
routine maintenance activity.
Required if the worst outcome could This is a team-based approach involving

have been a fatality, regardless of line managers, supervisors, health
High-level whether it is likely to recur or not. and safety managers and safety
representatives, ideally led by an
ELEMENT 1.4
impartial senior manager.
As mentioned at the beginning of this book, the aim of the NEBOSH HSE Introduction to Incident Investigation qualification is
to equip individuals to carry out non-complex incident investigations. It is, therefore, extremely important that the investigator
recognises when they are likely to be outside of their capability as investigators. Some incidents are extremely complex and as
such will require the appropriate expertise to undertake the investigation.
ELEMENT 1.5

1.3
Pre-investigation actions
The initial steps to take following an incident, but before an investigation begins, are to:
yy establish emergency response, such as first aid, and ensure the scene is safe;
ELEMENT 1.1
yy preserve the scene.
When making the scene safe it is important that you always assess your own safety and that of others. There can be a conflict
between making the scene safe and preserving it. However, in these cases the safety objective will always win.
The other initial steps that you must take are to:
yy gather witness contact details for interviews;
yy take note of any environmental conditions that may be relevant, such as icy ground or high winds;
ELEMENT 1.2
yy gather information on any equipment involved in the incident; and
yy decide whether the incident will be reportable under local legislation, for example, RIDDOR (which was discussed earlier
in this book). If it is reportable, the relevant authority must be notified within the timeframes set out in country-specific
legislation.
How soon an investigation should start will depend on the level of risk involved - in general, as soon as possible. Where
witnesses are to be interviewed, this should happen as quickly as possible to ensure witnesses do not have an opportunity to
ELEMENT 1.3
forget elements that could be relevant to the investigation. However, it must be noted that traumatised witnesses might just be
asked for an initial account of their observations and may need to be handled with sympathy.
The four-stage investigation process
ACTIVITY
Before we look at this section, what sort of evidence do you think you would gather for an incident
ELEMENT 1.4
investigation? Note down your ideas and we will revisit this list at the end of this section.
ELEMENT 1.5

32
1.3
The four stages in investigation are:
1. Gathering the information
2. Analysing the information
3. Risk control measures
ELEMENT 1.1
4. The action plan10
Gather the information
Gathering the Analysing the Risk control The action

1 2 3 4
information information measures plan
ELEMENT 1.2
It is important to capture information as soon as you are able to do so. This reduces the chance of it being tampered with,
such as equipment being moved, guards replaced, etc. Information gathered as quickly as possible is less likely to have been
tampered with, and therefore unbiased.
If necessary, work must be stopped, and everyone kept out of the area.
ELEMENT 1.3
Information relevant to the incident can be gathered in several ways:
yy physical evidence. This includes photographs of the scene, CCTV footage, observations, sketches, measurements and
details of the environmental conditions at the time;
yy verbal evidence. Witness statements (more on interview techniques

in 1.4). Talk to everyone who was close by when the adverse event
happened, especially those who saw what happened or know anything
about the conditions that led to it. Verbal information can also include
ELEMENT 1.4
opinions and experiences of all parties involved; and
yy written evidence. Documentary evidence/records such as risk assessments

and training records, as well as company policies and procedures.
This information should be recorded initially in note form, with a formal

report being completed once this stage of the investigation is concluded.
These notes should be kept at least until the investigation and report are
complete, so that they can be referred to in case of dispute.
ELEMENT 1.5

1.3
All of the above is considered to be evidence-based information gathering. The amount of time spent gathering information
should be proportionate to the level of investigation.
ACTIVITY
Looking back at the list you made at the beginning of this section, are there any additional types of evidence
you would add to it?
ELEMENT 1.1
ELEMENT 1.2
ELEMENT 1.3
Common themes during interviews

Interviewing witnesses can sometimes be challenging, and can test even the most calm-mannered interviewer. Interviewers may
ELEMENT 1.4
have to deal with:
yy forgetfulness, or a lack of clarity upon questioning;
yy closed answers; and
yy an unwillingness to participate due to fear of repercussions.
We will discuss this in more detail later in the book.

ELEMENT 1.5

34
1.3
Concept of barrier controls

Identifying barriers, such as safety or control functions
that have failed, is an important step in the information-
gathering stage of an investigation. The investigation needs
to establish how the risk should have been controlled (the
ELEMENT 1.1
benchmark standard). A barrier, such as a guard or a control
system, is supposed to create a safe or safer place of work.
If a critical barrier has failed and allowed an incident to
occur, the investigation will need to include looking at those
circumstances, for example:
yy somebody getting their fingers cut after they removed a

guard to clear a blockage; or Barrier to stop further adverse effects
ELEMENT 1.2
yy a blast wall failing, identifying a design fault.
THOUGHT PROVOKER
Thinking of your own workplace, what barrier controls does your organisation have in place?
ELEMENT 1.3
Analyse the information

1 2 3 4
ELEMENT 1.4
An analysis involves examining all the known and unknown facts and evidence relating to the incident. When reviewing the
evidence, the incident team should do this in an objective and unbiased way. They should review only the evidence in front of
them and not make suppositions.
yy Look at what is relevant to the incident, in a timely,

structured manner.
yy Have all reasonable lines of enquiry been followed? Is

there any information missing? If so, why?
ELEMENT 1.5
yy Establishing a timeline of the sequence of events and any

unsafe conditions or acts in the lead up to the incident
can help the structure of the investigation.
yy Analysis of interview statements should be undertaken

and common themes from these interviews recorded,
such as factors that contributed to the incident such as environmental conditions, housekeeping issues, etc.
yy All possible causes and consequences of the incident should be considered during this stage of the investigation.

1.3
ACTIVITY
Note down some of the findings you would expect an incident investigation to uncover after all information
has been gathered and analysed.
ELEMENT 1.1
ELEMENT 1.2
ELEMENT 1.3
After gathering all the information, you can then organise your findings in a systematic way. It is important to take account of
specific organisational tools or procedures when carrying out the analysis. Generally though, the analysis should:
yy Identify all causes of the incident:

ELEMENT 1.4
–– the immediate causes (the blade, the substance, the dust, etc);
–– the underlying causes (the guard removed, the ventilation switched off, etc);
–– the root cause (failure to identify training needs and assess competence, low priority given to risk assessment, etc).
yy Record all causes and risk control measures.
yy Ensure that control measures (existing and any additional control measures required) are identified for each cause found
during the investigation.
ELEMENT 1.5
A sequenced timeline can really help in determining relevance of information gathered and also assist in ensuring nothing is
forgotten during the investigation.
It is important to realise that not all of the findings from the investigation may have further actions and/or recommendations.

36
1.3
Risk control measures

1 2 3 4
ELEMENT 1.1
When considering risk control measures, it is important to take
account of all existing risk control measures. It may be that
existing risk controls are sufficient or it may be that they were
unused or broken at the time when the incident happened.
In terms of additional risk control measures, it is important that
ELEMENT 1.2
the following are considered:
yy Identify controls that will provide the best protection for

the majority of the workforce, rather than focusing on
the individual, eg, the implementation of a local exhaust
ventilation system over individual respiratory protective
equipment (this is discussed further under the hierarchy of
Unsafe practices for the movement of heavy boxes
control).
ELEMENT 1.3
yy Prioritise those measures that require implementation first, such as safety critical measures, or actions for a routine task
where the incident could easily recur.
When analysing risk control measures the investigation team must consider:
yy the legal implications of risk controls, or the implications of not making suggested changes;
yy any other standards that the organisation follows, eg sector-specific guidance; and
yy any standards created and implemented by the organisation.
ELEMENT 1.4
An action plan should be created with a realistic timescale for implementation.
When thinking about what risk control measures are needed or should be recommended, organisations should consider a
hierarchy of control. There are many different hierarchies which can be used. Here we will look at the hierarchy of control
contained within ISO 45001:2018.
yy Consider those measures that eliminate the risk before all else, eg use of inherently safe products.
yy Risk controls that substitute hazardous processes, operations, materials or equipment with less hazardous; the risk controls
ELEMENT 1.5
must have the ability to prevent recurrence of a similar or worse event.
yy Use of engineering risk controls that adequately control the risk at source (eg guards or local exhaust ventilation systems
which remove contaminants from the air such as wood dust in a carpentry shop). If engineering controls alone do not
adequately reduce the risk of recurrence then consider reorganisation of the work, eg are there any steps which could be
removed from a process to make it less hazardous?
yy Risk control measures can also include administrative controls such as having adequate training in place for all workers or
safe systems of work for hazardous procedures.
yy Lastly, consider measures that minimise risk by reliance on human actions, such as personal protective equipment (eg
safety footwear, gloves, head protection and respiratory protection).
1.3
ELIMINATION
SUBSTITUTION
ELEMENT 1.1
ENGINEERING CONTROLS
SIGNAGE/WARNINGS AND/OR
ADMINISTRATION CONTROLS
PERSONAL PROTECTIVE EQUIPMENT

ELEMENT 1.2
THOUGHT PROVOKER
Personal protective equipment is at the bottom of the hierarchy of control. Why do you think this is?
The most effective risk controls are those that create a safe or safer place, rather than relying on safe people.
ELEMENT 1.3
It is also important to remember that any recommendations for additional risk control measures should be based on the
outcomes of the investigation, eg evidence based.
Organisations must then consider whether similar risks exist elsewhere, where lessons can be learned from, or applied to.
yy In different departments of an organisation where a similar risk exists: the control measures should be considered for all
departments, to ensure the potential for recurrence is dealt with in the same manner throughout the organisation.
yy Organisations that have premises in different locations where the same or similar hazards exist: the control measures
ELEMENT 1.4
implemented in the area under investigation should be implemented throughout the organisation.
yy In different organisations: how do they manage this risk? Sharing best practice through industry forums can help
organisations learn lessons.
If an organisation has had similar incidents prior to an adverse event, they will need to determine:
yy whether they were investigated thoroughly after the last adverse event;
yy what additional risk control measures were put into place; and
ELEMENT 1.5
yy why it has been allowed to happen again, eg why did the existing or additional risk control measures fail.
Action should be taken more promptly in these circumstances.
Organisations who ignore safety failings are not looked kindly upon during any prosecutions or investigations, and this may be
reflected in the severity of any penalty issued by the state or judge.

38
1.3
The action plan

1 2 3 4
ELEMENT 1.1
ACTIVITY
Before we look at this section in detail, what sort of things would you expect the action plan to consider?
Note down some ideas and check whether you were right as the tutor goes through this section.
ELEMENT 1.2
ELEMENT 1.3
ELEMENT 1.4
The action plan is the outcome of a thorough incident investigation. At this stage, the top/
senior management of the organisation should be involved as they are the ones with the
power to act on the recommendations.
ELEMENT 1.5
The action plan should include:
yy risk control measures to deal with all immediate, underlying and root causes identified
during the investigation;
yy whether human error is a factor in the incident, and what can be done to reduce the chance of error occurring in future;
yy the identification of SMART (specific, measurable, achievable, realistic and time-bound) objectives to ensure that the
measures are implemented with the correct degree of priority;

1.3
yy a realistic timescale which needs to be assigned to each objective, and someone made responsible for that objective, to
ensure the action is taken within the specified timescale so it can then be closed out; and
yy which risk assessments/procedures need to be reviewed and updated.
Organisations will need to ask:

ELEMENT 1.1
yy Are there any trends that require further investigation?
yy What did the incident cost?
yy How are these findings and controls going to be communicated to interested parties and stakeholders?
yy How are the actions going to be tracked and closed out?
Organisations should ensure they keep their own records of incidents, their causes and the remedial measures taken. This will
ELEMENT 1.2
allow them to identify any trends that would require them to act more promptly or efficiently to prevent similar circumstances
and so improve their overall understanding and management of risk within their work activities.
It is also useful to estimate the cost of incidents to fully appreciate the true cost of incidents and ill health to your business.
Post investigation
After the investigation has concluded, it is particularly important that the findings of the investigation are communicated to all
the relevant people. It is important that the organisation learns lessons from the incident. It is also imperative that:
ELEMENT 1.3
yy the controls implemented are analysed to determine their effectiveness; and
yy witnesses and casualties are supported through any trauma they may have experienced.
If the incident had serious consequences, then access to the scene will usually be restricted to the investigation team plus other
third parties, eg unions and enforcement authorities. Once the investigation has been completed, the investigation team should
formally release the scene back to the operational unit as soon as is reasonably possible. This will allow ‘business as usual’ to
recommence.
ELEMENT 1.4
ELEMENT 1.5

40
1.3
References
10 Investigating accidents and incidents, HSG245, HSE Books http://www.hse.gov.uk/pubns/hsg245.pdf
ELEMENT 1.1
ELEMENT 1.2
ELEMENT 1.3
ELEMENT 1.4
ELEMENT 1.5

1.3
Notes
ELEMENT 1.1
ELEMENT 1.2
ELEMENT 1.3
ELEMENT 1.4
ELEMENT 1.5

42
1.4
Positive interview strategies and barriers to successful

interviews
ELEMENT 1.1
ELEMENT 1.2
The majority of this chapter will deal with the PEACE model which is used for successful interviewing. There are five stages to
the model:
ELEMENT 1.3
yy Planning and preparation.
yy Engage and explain.
yy Account, clarification and challenge.
yy Closure.
yy Evaluation.
ELEMENT 1.4
This chapter will take students through each stage and explain what is required to make your interviews successful.
The final section of the chapter will deal with barriers to good interviews, dealing with reluctant witnesses, blame culture and
how this could affect interviews and, finally, three types of bias which could affect the outcome of an investigation.
Learning outcome
yy Outline positive strategies that can be adopted for interviews following incidents and the barriers to successful interview
ELEMENT 1.5
outcomes.

1.4
Reasons for carrying out prompt interviews

Interviews should be undertaken as soon as possible following an incident to ensure an effective investigation, but also
because:
yy witnesses may forget things if not interviewed quickly;

ELEMENT 1.1
yy the brain can alter memories, especially after a trauma; and
yy if witnesses have an opportunity to discuss the incident among themselves, their memories may be altered by other people's
opinions.
The PEACE model for interviewing

The PEACE model for interviewing is used by many different agencies, including the police service and government
ELEMENT 1.2
departments. A lack of structure and planning during the interview process can result in:
yy critical information not being captured;
yy loss of confidence in the investigation team due to the inability to capture sensitive information; and
yy a witness not being truthful, or being reluctant to participate in the interview process.
PEACE stands for the following elements to be covered during the interview process:
ELEMENT 1.3
P planning and preparation
E engage and explain

ELEMENT 1.4
A account, clarification and challenge
C closure
ELEMENT 1.5
evaluation
E

44
1.4
P Planning and preparation
This stage is essentially the process behind getting ready for the interview, and all elements should be reviewed and agreed
before starting the interview process, to ensure the best methods are adopted.
ELEMENT 1.1
yy Getting the location right is important – somewhere quiet, without distractions or interruptions. It is also important to
consider whether the interview should be held on or off site. There are benefits and limitations to holding interviews on site.
Some of the benefits include:
–– the incident site can be visited during interview to clarify positions;

–– interviewees will be familiar with the site; and
–– it feels less formal so may make an interviewee feel more comfortable.
ELEMENT 1.2
Limitations include:
–– interruptions during interview, due to the proximity; and

–– post-traumatic stress for the interviewee after witnessing an incident in the vicinity of the interview room.
yy Allow sufficient time for the interview to be conducted thoroughly, how ever long that may take. There is a possibility that
an interviewee may need time out to compose themselves.
yy Prepare an interview plan, based on the facts that need to be established – ie aims and purpose of interview. This can be
ELEMENT 1.3
determined by what is already known, and what needs to be uncovered.
yy Establish a timeline to plot the sequence of events during interview – it can even be helpful to have this in the vicinity
during the interview.
yy Creating a checklist prior to interview can help ensure all relevant areas are covered.
yy Interview one person at a time, and use a scribe* to help the interview flow better. This is the ideal situation but there may
be times when other people will be required to be in the interview room. Examples of this include:
ELEMENT 1.4
–– trade union/worker body representation;
–– translator;
–– buddy;
–– Human Resources representative; and
–– solicitor/lawyer who may be representing either the employer or the interviewee.
* In some cases, audio or video recording of the interview in place of or as well as a scribe may be required.
ELEMENT 1.5

1.4
ACTIVITY
Can you think of any other benefits and limitations of conducting interviews on site in addition to those
mentioned earlier?
ELEMENT 1.1
ELEMENT 1.2
ELEMENT 1.3
E Engage and explain

ELEMENT 1.4
At this stage, it is important to establish a number of points

with the interviewee, to ensure the best outcome is achieved.
yy Set out the aims and objectives of the interview (please also
see Element 1.3) – it is important to explain these to the
interviewee.
ELEMENT 1.5
yy Assess any individual needs of the interviewee – comfort,

refreshments, etc.
yy Establish a rapport with the interviewee – engaging the

interviewee in conversation will help put them at their ease.
Assessing the needs of the interviewee

eg refreshments

46
1.4
In order to get the most successful outcome from each interview, the following guidelines should be followed:
yy use open questions to begin with, to gather the initial information;
yy never use leading questions, or prompt an answer from an interviewee – not only can this lead to incorrect information
being gathered, it can also make the interviewee lose trust and respect for the person doing the interview;
ELEMENT 1.1
yy closed, targeted questions can be used after the initial information gathering, to establish specific facts;
yy avoid the use of jargon – speak in a language that the interviewee will understand and relate to; and
yy ensure the initial rapport established is continued throughout the interview, ensuring the interviewee is at ease and
comfortable.
THOUGHT PROVOKER
ELEMENT 1.2
Why do you think closed questions should not be used during the initial information gathering part of the
interview?
Active listening
Active listening can be one of the most important tools that an incident
investigator/interviewer can have. Active listening will enable you to
successfully gather information. Incident investigators should be able to
ELEMENT 1.3
absorb and understand the information given by an interviewee without
interruption.
Good incident investigators need to learn to listen first and speak second
so that meaningful balanced communication always takes place. People
have two ears but one mouth… what does this tell you?
Active listening is not the same as hearing. Hearing is about being aware
of sounds. Listening requires action; you need to concentrate so that you
ELEMENT 1.4
process and understand the meaning of the message and can respond accordingly.
This is often represented using four stages: hearing, attending, understanding and remembering.
Hearing is simply being aware of a sound.
Attending is the act of filtering and screening, so you actually pay attention to the message. This is particularly important (and
difficult) if you have issues with the person delivering the message. We need to listen through our prejudices and focus on the
message not the messenger.
ELEMENT 1.5
Understanding means we comprehend what is being said and decode the information we are being given. You should not
just switch off until it is time for you to speak again. Listening properly is the only way we can really understand what people
need, or what they think about a particular issue or idea.
Remembering means committing information to memory, an essential requirement for active listening. It is also the only way
to ensure continuity and the important act of building rapport. It is not always easy to do, so make notes if needed. There is
little point in a conversation, the sending and receiving of information through a communication channel, if the content of this
exchange is instantly lost.

1.4
THOUGHT PROVOKER
Think back to conversations you have had with your colleagues or friends or family. Do you think that you
actively listen or do you simply ‘hear’?
ELEMENT 1.1
A Account, clarification and challenge
Any interview undertaken must continue until all relevant information is gathered, so it is important that interviews are not
interrupted and re-started at a later date.
Once all information has been given by the interviewee, it can then be analysed by the investigation team, who will establish:
ELEMENT 1.2
yy areas for further exploration/investigation – where more information is

required;
yy any inconsistencies in evidence gathered to further clarify with the

interviewee, such as differences in times or activities being carried out at
the time; and
yy any contradictions from the interviewee based on other evidence gathered,

which may not always be intentional.
ELEMENT 1.3
Summarise answers using the interviewee’s own language, eg clarifying an answer before challenging inconsistencies or
contradictions.
C Closure
All information must be summarised using the interviewee’s own words. This can be carried out by either the interviewer
ELEMENT 1.4
or scribe and this should preferably be done before the close of the interview. This will ensure that there is not a start/stop
element to the interview eg, no unnecessary interruptions. In some circumstances it may also be necessary to arrange for the
information obtained to be formally documented and signed by the interviewee.
All interviewees must confirm that the statement recorded is a factual and accurate account of what they said.
The next steps should then be explained to each interviewee prior to leaving the interview room, eg they may need to be
contacted or interviewed again as the investigation continues to clarify further points as things come to light.
Contact details for the interviewee should be taken at this time to ensure they can be contacted swiftly in this event.
ELEMENT 1.5
E Evaluation
At this stage, the interviewer should review their initial aims and objectives to determine whether they were met. This involves:
yy evaluating the information received during the interview, and the relevance of it to the incident and investigation;
yy comparing this with other evidence and identifying further points to be clarified or missing pieces of information; and

48
1.4
yy reviewing their own performance to ensure they met PEACE criteria for the most effective interview, and how this could be
improved upon if necessary. Self-critique is an important part of the process – if an interviewee became closed and guarded
at any point, it may have been a reaction to the interviewer’s behaviour or language as opposed to anything else.
Barriers to good interviews
ELEMENT 1.1
We will now look at what can negatively influence an interview.
yy An interviewer may ask leading or closed questions, causing the interviewee to say little, or stop talking altogether.
yy A language barrier might make the entire communication process difficult, and lead to more targeted questions being
asked.
yy Poor communication skills from either party may affect the quality of the interview/evidence.
ELEMENT 1.2
yy The interviewer may not actively listen to the interviewee, causing tension between parties.
yy The interviewee may be in shock after the event so may not think rationally, or they may be too scared of repercussions to
be honest.
yy It may be that interviewees have heard rumours or already have formed opinions based on hearsay and may therefore add
this hearsay to their account.
Reluctant or unwilling interviewees
ELEMENT 1.3
Witnesses may be reluctant to provide information during an
investigation as they may be:
yy concerned about the repercussions in the workplace; and/or
yy worried they may implicate themselves.
Any interviewer must work to ensure that the interviewee is

fully aware that the reason for the investigation is to identify
ELEMENT 1.4
the causes, and not to apportion blame or pass judgement on
involved parties.
In extreme circumstances, the investigation team may allow an

interviewee to give their evidence anonymously, where they are
Unwilling interviewee
genuinely concerned about the outcome.
ELEMENT 1.5

1.4
Blame culture
KEY TERMS
Blame culture
ELEMENT 1.1
“The tendency to look for one person or organisation that can be held responsible for a bad state of affairs,
an accident, etc.”
Collins English Dictionary Copyright ©HarperCollins Publishers
It is likely you will have encountered the term ‘blame culture’,

which should be self-explanatory. A blame culture is the default
culture due to human beings’ inherent need to put blame
ELEMENT 1.2
outside of ourselves.
An organisation that has a blame culture seeks to find out who

is responsible, so that blame can be attributed to an individual
or group of people. This could lead to punishment, possibly
disciplinary action, maybe dismissal, perhaps some retraining
and certainly the blame for the incident being placed on an
individual or group. You may consider this fair or not, but if
ELEMENT 1.3
the focus is on blaming people, this culture will not encourage

the sharing of information on actions that led to errors; people
do not want to be blamed! In this culture, people are unlikely to share this knowledge or report incidents as they are afraid of
recriminations. There will also usually be a lack of organisational learning where a blame culture exists.
It is, therefore, unlikely that a ‘blame culture’ is going to lead to long-term improvement of health and safety. Blaming people
often seems to provide an easy way to show that ‘justice has been done’, and is certainly less complex and time-consuming
than properly investigating the issue, reviewing and changing processes and procedures; this is why ‘blame culture’ seems so
prolific.
ELEMENT 1.4
As mentioned earlier, a blame culture is a default ‘setting’. Workers within an organisation can believe that their organisation
has a blame culture (default setting) when, in fact, this is not the case. However, just the belief in an organisational blame
culture can be enough to stop workers reporting incidents.
Essentially, where people feel they are likely to be held accountable for their part in an incident, or likely to be blamed for an
equipment fault or error, they are far less likely to be open and honest about their role in the incident during an interview. This
perception on the part of the interviewee can greatly hinder an investigation. However, in some cases, the investigation may
conclude there was one or more individuals at fault. Individual fault should only be identified as a last resort when all avenues
ELEMENT 1.5
for organisational learning have been exhausted.

50
1.4
ACTIVITY
What sort of pressures do you feel an investigator will need to deal with if they operate in an organisation
with a blame culture?
ELEMENT 1.1
ELEMENT 1.2
ELEMENT 1.3
Bias
ELEMENT 1.4
KEY TERMS
Bias
"Inclination or prejudice for or against one person or group, especially in a way considered to be unfair."
Oxford Dictionary of English
Bias is sometimes referred to as ‘strong inclinations’, and it

is particularly important that any internal investigation is not
ELEMENT 1.5
affected by bias, as it can mean that important issues that

could be uncovered during an investigation go unquestioned or
unnoticed.
Bias among the investigation team can also sometimes greatly

affect the outcome of an investigation.

1.4
Biases can cause someone to feel or display an inclination or prejudice for or against someone or something. Perception bias
can occur in an incident investigation as people perceive things in different ways. When people are rapidly making decisions
and forming thoughts based on the facts in front of them, they can subconsciously form a perception bias based on the
shorthand the brain develops to help us make those decisions quickly. Other factors, such as social pressure, can affect how we
perceive situations or people, even when we believe we are being impartial, by making assumptions.
ELEMENT 1.1
Cherry picking bias

Cherry picking is a type of confirmation bias, where a person
will overlook sometimes vital elements, and focus only on
elements that confirm the notion that they already believe to be
correct. This type of bias can be very detrimental to an effective
investigation. People can cling on to their perceived beliefs even
when evidence has been brought to light that challenges that
ELEMENT 1.2
perception or belief.
It is vitally important that these assumptions are challenged

by the investigation team to ensure the conclusions made are
not affected by perceived beliefs, and the wrong conclusions
drawn. This type of bias can very often be present in smaller
organisations where familiarity with the workforce, work areas
and equipment can result in opinions being cemented prior to
any incident.
ELEMENT 1.3
Self-serving bias
KEY TERMS
Self-serving bias
“A tendency for individuals to attribute their own successes to personal strengths, such as talent, and their
failures to external circumstances, such as bad luck.”
ELEMENT 1.4
This cognitive bias will protect self-esteem – if people attribute

positive results to their individual characteristics, it can be
a much-needed confidence boost. By attributing failures to
outside conditions or forces, it protects that self-esteem and
absolves the individual of personal responsibility.
ELEMENT 1.5
This can be counter-productive in an investigation. If the

internal investigation team are willing to blame external factors
for everything, they potentially bypass the opportunity to affect
improvement. The team may believe there is little they can do
to influence or change the situation as it is perceived to be ‘out
of their control’.
Attributing positive results to own personal effort and talent
For an effective investigation to be carried out, it is important
for the investigation team to look at the organisation first, before considering any other external factors.

52
1.4
ACTIVITY
What behaviours might a witness display during an interview that could be self-serving bias?
ELEMENT 1.1
ELEMENT 1.2
ELEMENT 1.3
ELEMENT 1.4
ELEMENT 1.5

1.4
Fundamental attribution error

ELEMENT 1.1
ELEMENT 1.2
KEY TERMS
ELEMENT 1.3
Fundamental attribution error
“A pervasive tendency to underestimate the importance of external situational pressures and to overestimate
the importance of internal motives and dispositions in interpreting the behaviour of others.”
Fundamental attribution error is also known as correspondence bias, or attribution effect. It is essentially the tendency for
someone to focus on personal characteristics, or internal attributes, as opposed to situational or external circumstances that
ELEMENT 1.4
may have influenced a person’s behaviour or choices. An example of this would be assuming that someone caused an accident
by rushing, as it is in their nature to be rushing around.
This type of bias could be applied in a situation even where the investigator didn’t know the person under investigation, where
they could assume certain personal characteristics about the person, without even considering the job or organisational factors.
It is vitally important that these assumptions are challenged by the investigation team to ensure the conclusions made are not
affected by any of these types of bias. Investigations affected by bias could lead to the wrong conclusions being drawn.
ELEMENT 1.5

54
1.4
ACTIVITY
Group discussion: Can you think of five more examples of fundamental attribution error?
ELEMENT 1.1
ELEMENT 1.2
ELEMENT 1.3
ASSESSMENT
Element 5 is an introduction to advanced incident investigation techniques and does not form part of the
assessment for this qualification. It is, therefore, time to complete the assessment activities. The accredited
ELEMENT 1.4
course provider will give further instructions but please also refer to the ‘Guidance and information for students and
internal assessors’ which is downloadable from the NEBOSH website www.nebosh.org.uk.
ELEMENT 1.5

1.4
Notes
ELEMENT 1.1
ELEMENT 1.2
ELEMENT 1.3
ELEMENT 1.4
ELEMENT 1.5

56
1.5
Introduction to advanced incident investigation techniques
ELEMENT 1.1
ELEMENT 1.2
Throughout this book we have talked about a simple incident investigation method. However, there are other techniques which
will aid an investigation. This chapter will introduce four of these to the student.
ELEMENT 1.3
Learning outcome
yy An introduction to advanced incident investigation techniques.
ELEMENT 1.4
ELEMENT 1.5

1.5
Root cause analysis: advanced incident investigation techniques

ELEMENT 1.1
ELEMENT 1.2
ELEMENT 1.3
ELEMENT 1.4
This book has looked at simple incident investigation. However, there are a range of different advanced methods which can
be used in the investigation of an incident. We are now going to look briefly at four of these techniques. The techniques
are graphical representations of an incident. They can be quantified but in their simplest format can be used to immediately
ELEMENT 1.5
identify the root cause of an incident.
‘5 Whys’ technique
The ‘5 Whys’ is a technique used as part of an investigation to find the exact reason that causes a problem and can be a very
effective problem-solving tool. By asking a sequence of ‘why’ questions – five is a good rule of thumb – we can circumnavigate
the layers of issues that may surround a problem. This method can also be used to identify immediate, underlying and root
causes of an incident. An example of this follows.

58
1.5
WORKER FRACTURES A WRIST AFTER

TRIPPING OVER AN ELECTRICAL CABLE
ELEMENT 1.1
WHY?
The cable trailed AND He tripped over AND He didn’t see

across the floor the cable the cable
ELEMENT 1.2
WHY? WHY? WHY?
It was left there It lay across It was dark where

by a contractor his path he walked
WHY? WHY? WHY?
ELEMENT 1.3
No control of Two out of these No one asked for
Lack of site
contractors AND lights were not AND the bulbs to be
supervision
system in place working replaced
ELEMENT 1.4
WHY? WHY? WHY?
Management Supervisor didn’t No system existed

didn’t know they know he was for routinely
needed a policy responsible for checking the
for this checking this lights
ELEMENT 1.5
It was en route
to where he
was going

1.5
Fault tree analysis

Fault tree analysis is a deductive analysis of a failure, or undesired state of a system. The main purpose is to help identify
potential causes of system failures, and the impact of those failures, before they occur. It is often used in system design, to
allow for fail-safes to be added into the system, to prevent the undesired state from occurring. An example of a simple fault
ELEMENT 1.1
tree analysis format follows.
Undesired event
ELEMENT 1.2
Or gate
Process/component Process/component
failure failure
ELEMENT 1.3
And gate
Or gate
ELEMENT 1.4
Event Event Event Event

ELEMENT 1.5

60
1.5
Event tree analysis

Event tree analysis is a technique used to evaluate a process or activity, and the events leading up to a potential or actual
incident. This method analyses a sequence of actions and events (starting from the initiating event on the left through to
the outcome of the incident on the right). Analysis starts at the initiating event and the consequences of the event are then
ELEMENT 1.1
followed through a series of possible outcomes. Logic models and diagrams are sometimes used to assist in this method. An
example of a simple event tree analysis format follows.
Event 2 Event 3 Event 4 Outcome
Succeed
Succeed Goal achieved
Succeed Goal not achieved

Fail
Succeed
ELEMENT 1.2
Goal not achieved
Initiating event
Fail Goal not achieved
Fail
Goal not achieved
Fail
Cause and effect analysis/fishbone diagram
ELEMENT 1.3
Cause and effect analysis is a technique that can help to visualise all the potential or likely root causes of a problem. A full and
thorough analysis of the situation can analyse processes and the impact of issues or hindrances on the business. This analysis
can be used both in planning, looking at potential future problems and their impact, or previous issues/incidents, looking back
at the impact that they had, and for solutions to prevent a recurrence. The diagram created is known as a ‘fishbone diagram’,
as the final diagram looks like a fish skeleton.
OPTION 1 OPTION 2 OPTION 3
ELEMENT 1.4
CAUSE CAUSE CAUSE
CAUSE CAUSE
CAUSE
EFFECT
CAUSE
CAUSE CAUSE
ELEMENT 1.5
CAUSE CAUSE CAUSE
OPTION 4 OPTION 5 OPTION 6
The ‘options’ which are used vary between industries. For example, manufacturing industries tend to use machines, methods,
materials, measurements, Mother Nature (the environment) and manpower (people).

1.5
Notes
ELEMENT 1.1
ELEMENT 1.2
ELEMENT 1.3
ELEMENT 1.4
ELEMENT 1.5

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INTRODUCTION TO

Element 1 Introduction to incident investigation 3

1.1 Incident terminology, arguments for investigations and management system

1.2 Human and organisational factors 19

1.5 Introduction to advanced incident investigation techniques 57

Incident terminology, arguments for investigations and

NEBOSH HSE Introduction to Incident Investigation 3

An adverse event that results in injury or ill health.

Occurrences Regulations 2013 (RIDDOR).

As detailed in HSG245: ‘Investigating accidents and incidents’

NEBOSH HSE Introduction to Incident Investigation

yy resulting injuries from falls from height;

yy blunt or penetrating trauma.

yy burns that do not require skin grafting/surgery;

yy sprains and strains, or ligament damage;

yy whiplash-type injuries; and

yy tripping over a trailing cable;

yy falling down a step;

yy an unattended ladder slipping down a wall due to lack of securing; and

yy falling over uneven ground.

NEBOSH HSE Introduction to Incident Investigation 5

yy a collapse or partial collapse of a scaffold over five metres tall;

yy an overturn of any load-bearing part of lifting equipment;

yy contact with overhead power lines;

yy accidental release of a flammable substance of certain quantities.

yy a fall from a step-ladder causing a sprained ankle; or

Why do we investigate incidents?

NEBOSH HSE Introduction to Incident Investigation

Moral, legal and financial arguments for investigations

The legal argument

The penalties in terms of fines and imprisonment apply to

yy occupational diseases; and

Where the regulators are involved in the incident

yy organisations must take steps to ensure that the

NEBOSH HSE Introduction to Incident Investigation 7

NEBOSH HSE Introduction to Incident Investigation

NEBOSH HSE Introduction to Incident Investigation 9

The moral argument

NEBOSH HSE Introduction to Incident Investigation

The financial argument

NEBOSH HSE Introduction to Incident Investigation 11

Management system requirements (ISO 45001)

include incident investigations to manage incidents.

When an incident (non-conformity) occurs, the standard

yy Try to prevent recurrence through worker involvement

–– investigating the incident;

–– finding the cause(s) of the incident;

Leading and lagging indicators of health and safety performance

pivotal part of that requirement.

yy injury frequency and severity;

yy reportable incidents; and

yy worker claims and compensation costs.

yy number of health and safety training sessions carried out;

yy hazard spotting and reporting;

yy safety articles, eg HSE bulletins or OSHA news releases;

yy initiatives to improve safety culture;

yy positive feedback and recognition for health and safety performance;

NEBOSH HSE Introduction to Incident Investigation

yy risk assessment, management and control;

yy safety culture surveys among the workforce;

yy safety audits and inspections; and

The role of insurers in incident investigation

yy Organisations may be refused insurance in certain areas if they

yy Insurers (along with shareholders, etc) will want assurance

1.1 Incident terminology, arguments for investigations and management system

1.5 Introduction to advanced incident investigation techniques 57