The Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR 2013) requires employers and persons in control of workplaces to inform the Health and Safety Executive (HSE) about certain ”Adverse events”

If someone has died or has been injured because of a work-related accident this may have to be reported. Not all accidents need to be reported, other than for certain gas incidents, a RIDDOR report is required only when:

• the accident is work-related
• it results in an injury of a type which is reportable

It is recommended that all accidents and incidents (near misses or undesired circumstances, dangerous occurrences, etc.) that could occur whilst you are at work are investigated this is in order to help prevent a re-occurrence in the future. It is useful if you are aware of the terminology in use around adverse events.

Lets look at some definitions:

An accident can be described as an unwanted event that results in injury, damage, loss or ill health.

An incident can be a variety of things such as:

• A near miss: which is an event that, while not resulting in harm, has the potential to cause injury or ill health and can include a dangerous occurrence.

• Undesired circumstance: a set of conditions or circumstances that have the potential to cause injury or ill health, e.g. climbing a partially completed scaffolding before it has been inspected and passed as complete.

• A dangerous occurrence: could be one of a number of specific events for a list of what dangerous occurrences needs to be reported either refer to the RIDDOR or for further guidance contact affersafety to ensure that you are complying with the law

A hazard is defined as something with the potential to cause harm, including ill health and injury; damage to property, plant, products or the environment, production losses or increased liabilities.

A risk is defined as the level of chance or likelihood* that harm, damage or loss could happen as a result of exposure to the hazard and the severity* of harm, damage or loss. For example ask yourself; how often is it likely to happen, how many people could be affected and how bad would the likely injuries or ill health effects be?

* see below

In order to reduce the risks to tolerable levels you are likely to introduce risk control measures which are the workplace precautions put in place to reduce the risk.

When investigating accidents or incidents we need to be aware of some other definitions; 

Immediate cause: this is the most obvious reason why something has happened, usually the answer to ”what went wrong?” e.g. the ladder wasn”t long enough, the ground was uneven etc. It is not unusual if there are several immediate causes identified in any one adverse event.

In terms of consequence or *severity referred to above the following definitions apply:

fatal: work-related death, either single or multiple;

Types of reportable injury

The death of any person

All deaths to workers and non-workers, with the exception of suicides, must be reported if they arise from a work-related accident, including an act of physical violence to a worker.

Specific injuries

The list of ‘specified injuries’ in RIDDOR 2013 replaces the previous list of ‘major injuries’ in RIDDOR 1995. Specified injuries are (regulation 4):

• fractures, other than to fingers, thumbs and toes
• amputations
• any injury likely to lead to permanent loss of sight or reduction in sight
• any crush injury to the head or torso causing damage to the brain or internal organs
• serious burns (including scalding) which:
  • covers more than 10% of the body
  • causes significant damage to the eyes, respiratory system or other vital organs
• any scalping requiring hospital treatment
• any loss of consciousness caused by head injury or asphyxia
• any other injury arising from working in an enclosed space which:
  • leads to hypothermia or heat-induced illness
  • requires resuscitation or admittance to hospital for more than 24 hours
    
    
    

Over-seven-day incapacitation of a worker

Accidents must be reported where they result in an employee or self-employed person being away from work, or unable to perform their normal work duties, for more than seven consecutive days as the result of their injury. This seven day period does not include the day of the accident, but does include weekends and rest days. The report must be made within 15 days of the accident.

Over-three-day incapacitation

Accidents must be recorded, but not reported where they result in a worker being incapacitated for more than three consecutive days. If you are an employer, who must keep an accident book under the Social Security (Claims and Payments) Regulations 1979, that record will be enough

Non-fatal accidents to non-workers (e.g. members of the public)

Accidents to members of the public or others who are not at work must be reported if they result in an injury and the person is taken directly from the scene of the accident to hospital for treatment to that injury. Examinations and diagnostic tests do not constitute ‘treatment’ in such circumstances.

There is no need to report incidents where people are taken to hospital purely as a precaution when no injury is apparent.

Occupational diseases

Employers and self-employed people must report diagnoses of certain occupational diseases, where these are likely to have been caused or made worse by their work: These diseases include (regulations 8 and 9):

• carpal tunnel syndrome;
• severe cramp of the hand or forearm;
• occupational dermatitis;
• hand-arm vibration syndrome;
• occupational asthma;
• tendonitis or tenosynovitis of the hand or forearm;
• any occupational cancer;
• any disease attributed to an occupational exposure to a biological agent
  
  

Reportable dangerous occurrences

Dangerous occurrences are certain, specified ‘near-miss’ events (incidents with the potential to cause harm.) Not all such events require reporting. There are 27 categories of dangerous occurrences that are relevant to most workplaces. For example:

• the collapse, overturning or failure of load-bearing parts of lifts and lifting equipment;
• plant or equipment coming into contact with overhead power lines;
• explosions or fires causing work to be stopped for more than 24 hours.

Certain additional categories of dangerous occurrences apply to mines, quarries, offshore workplaces and certain transport systems (railways etc.).

Reportable gas incidents

If you are a distributor, filler, importer or supplier of flammable gas and you learn, either directly or indirectly, that someone has died, lost consciousness, or been taken to hospital for treatment to an injury arising in connection with the gas you distributed, filled, imported or supplied, this can be reported online.

If you are a gas engineer registered with the Gas Safe Register, you must provide details of any gas appliances or fittings that you consider to be dangerous to the extent that people could die, lose consciousness or require hospital treatment. This may be due to the design, construction, installation, modification or servicing, and could result in:

• an accidental leakage of gas;
• inadequate combustion of gas; or
• inadequate removal of products of the combustion of gas.
  
  

For further guidance on accident investigation and reporting accidnets and incidents contact affersafety to ensure that you are complying with the law.

RIDDOR 2013 Changes

From 1 October 2013, RIDDOR 2013 comes into force, which introduces significant changes to the existing reporting requirements. The main changes are to simplify the reporting requirements in the following areas:

• the classification of ‘major injuries’ to workers is being replaced with a shorter list of ‘specified injuries’;
• the previous list of 47 types of industrial disease is being replaced with eight categories of reportable work-related illness;
• fewer types of dangerous occurrence require reporting.
  
  

There are no significant changes to the reporting requirements for:

• fatal accidents;
• accidents to non-workers (members of the public);
• accidents which result in the incapacitation of a worker for more than seven days.
  
  

Recording requirements remain broadly unchanged, including the requirement to record accidents resulting in the incapacitation of a worker for more than three days.

Further definitions pertaining to the investigation of adverse events.

Root cause: the base cause, initiating event or failing from which all other causes or failings spring. Root causes are generally high level failings in management, planning or organisation.

Underlying cause: are less obvious ‘systems’ or ’organisational’ reasons for an adverse event happening, e.g. pre-works machinery checks not carried out by operators / supervisors; hazards not adequately considered in a suitable and sufficient risk assessment; time pressures too great etc.

Why investigate adverse events?

Hazards exist in all workplaces which is why we put in place risk control measures to reduce the risks to an acceptable level and to prevent accidents and cases of ill health from happening. If an adverse event happens then this suggests that the existing risk control measures are inadequate.

We need to investigate the circumstances surrounding the adverse event in order to find the causes (immediate, underlying and root) and develop a plan to prevent a re-occurrence. We will look at learning lessons from near misses which can prevent costly accidents. E.g. the Clapham Junction rail crash or the Herald of Free Enterprise ferry disaster these were both examples of situations where management had failed to recognise, and act on, previous failings in the system.

Legal reasons for investigating

• To ensure you and your company are operating within the law.

• Regulation 5 of The Management of Health and Safety at Work Regulations 1999, requires employers to plan, organise, control, monitor and review their health and safety arrangements. Investigations into adverse events will form an essential part of this process.

• The Woolf Reporton civil action means that you are expected to make full disclosure of the circumstances of an accident to the injured parties considering legal action. If the fear of litigation makes you think it is better not to investigate, the fact that you thoroughly investigated an accident and took remedial action to prevent further accidents would demonstrate to a court that your company has a positive attitude to health and safety. And of course you can’t make things better if you don’t know what went wrong! Your investigation findings will also provide essential information for your insurers in the event of a claim.
  
  

Which events should you investigate?

Following such an incident, you will need to decide whether an adverse event you have been made aware of should be investigated and if so, in what depth.

You will need to consider what the potential consequences are and the likelihood of a re-occurrence of the adverse event and that should help you determine the level of investigation. Similarly, the causes of a near miss can have a potential to cause injury and ill-health. When making your decision, you should also consider the potential for learning lessons. For example you should consider whether you have had a number of similar adverse events, if so, it may be worth investigating, even if each single event is not worth investigating in isolation. It is best practice to investigate all adverse events which may affect the public.

Who should carry out the investigation?

It is essential that the workforce as well as the management are fully involved if an investigation is to be worthwhile. For higher levels of investigation people such as supervisors, line managers, health and safety professionals, employee representatives and senior management/directors may all be involved.

A joint workforce / management approach will ensure that a full range of practical knowledge and experience will be to hand and employees and their representatives are more likely to support any remedial measures that are necessary. A joint approach also reinforces the message that the investigation is for the benefit of everyone.

Workforce representatives being with them the benefit of detailed knowledge of the work activities involved. The investigation team members should be familiar with health and safety good practice, standards and legal requirements and should include people who have the necessary investigative skills. The team must have sufficient time and resources to carry out the investigation efficiently.

It is highly recommended that the investigation team is led by someone with the authority to make decisions and act on their recommendations.

When should it start?

This will depend on the magnitude and immediacy of the risk involved (e.g. a major accident involving an everyday job will need to be investigated quickly). A good rule of thumb is that all adverse events should be investigated and analysed as soon as possible. This is common sense as well as good practice as memories can tend to fade quiet soon after an adverse event.

What does it involve?

An investigation will necessarily involve an full analysis of all the information available, including interviewing witnesses, preserving physical evidence (the scene of the incident), and looking at written documentation relevant to any ongoing work (risk assessments, method statements, procedures, instructions, job guides etc.), to find out what went wrong and determine what steps must be taken to prevent a re-occurrence of the adverse event.

All participants must be open, honest and objective throughout the investigation process. They should not form any pre-conceived ideas about the process, the equipment or the people involved as these might divert the thoughts of the individuals away from the real causes.

What makes a good investigation?

As the saying goes ”to get rid of weeds you must dig up the root. If you only cut off the foliage, the weed will grow back again”.

Simply dealing with the immediate causes of an adverse event may only provide a short-term solution. But, in time, if the underlying/root causes are not addressed conditions will be allowed to develop where further adverse events are likely, with the likelihood of more serious consequences. It is imperative that the immediate, underlying causes and root causes are all identified and remedied.

Investigations need to be conducted with accident prevention, not blame, in mind. Operating a blame culture and looking for a culprit before the investigation has started is counterproductive. People will become defensive and uncooperative as they are likely to suspect that a ”witch hunt” is being carried out. Only after the investigation has been fully completed can it be appropriate to consider whether any individuals acted inappropriately.

It is rarely acceptable to conclude an investigation with sole blame being apportioned to operator error. It will be unusual indeed if the ‘human error’ was not accompanied by a number of underlying causes that created the ideal environment in which human errors were inevitable.

The objective of the investigation is to establish how the adverse event happened as well as what allowed it to happen. The root causes of adverse events are almost always management, organisational or planning failures.

You will need to look carefully at your health and safety policy and how it is reflected in the workplace. Is it properly understood by employees and the health and safety message that relates to their work? Is there something missing from the policy? Is it implemented, or is management not enforcing the health and safety message and ensuring that health and safety measures remain in place and are effective at all times? If not, your health and safety policy needs to be changed.

This is another area where affersafety can be of service to you please call 01352 780098 or 07968 381445 or email info@affersafety.co.uk