Investigation - Stage 3: Prepare the investigation - Additional guidance
Core objectives
The following seven core objectives apply to all investigations.
It is not necessary to formally record them every time, although you may choose to do so. The core objectives will be SMART provided adequate resources are made available and realistic deadlines are set.
Identify the relevant dutyholder(s) and witnesses
This should be a priority objective, as dutyholders need to be identified as soon as possible so that intelligence can be gathered in the preparation stage.
Possible enforcement action and responsibility for any remedial action will also need to be correctly targeted at the responsible dutyholder(s).
Witnesses need to be identified quickly so that information can be obtained to inform the early stages of the investigation
Establish the key facts relating to the causes of the incident
Guidance and training are currently being developed covering methods and tools that can help the investigation establish the sequence of events, and so deliver this objective.
Identify immediate and underlying causes
The following definitions of immediate and underlying causes apply:
- Immediate (or direct) causes are the unsafe acts or conditions that initiated the undesired event(s) under investigation. For example, where a pipe is fractured and releases its contents when struck by a vehicle, the immediate cause of the incident would be the vehicle impact.
- Underlying (or root) causes are the failings that allowed the unsafe acts or conditions that initiated the undesired event(s) to arise. Underlying causes should be explored fully as they are usually arise from organisational or safety management systems failings.
In the example of the vehicle fracturing the pipe, underlying causes might include:
- driver competency issues arising from lack of training and inadequate management systems to assure competency, eg using driver permits
- inadequate vehicle maintenance arising from poor work scheduling because of a flawed maintenance system and poor management of resources and priorities
- unsuitable location of pipework arising from poor design and lack of awareness of hazard potential due to failure to assure competency of designers and risk assessors.
Guidance and training are currently being developed covering investigative methods and tools that can help deliver this objective.
Identify any lessons learned
Lessons learned are the findings from an investigation about measures needed to prevent further similar incidents based on what went wrong (key facts) and why (underlying causes). These lessons should form the basis of any recommendations for remedial action.
Lessons can be extracted from any aspect in the chain of events to offer valuable learning. However, lessons that address underlying rather than immediate causes will usually offer a sound basis for action to prevent recurrences. The lessons learned may also have wider implications, beyond the dutyholder directly involved.
Ensure appropriate remedial action is taken to prevent a recurrence
You need to be clear about exactly what is to be achieved and by whom.
To ensure remedial action will prevent a recurrence you should be satisfied that underlying causes are addressed. You should also consider how far any findings should be shared/acted on.
Appropriate remedial action may involve:
Direct remedial action with dutyholder(s) involved in the investigated incident
The dutyholder(s) would normally be responsible for implementing remedial action at the site of the incident and on other sites they may operate.
Ensuring remedial action is taken may involve influencing dutyholder(s), monitoring progress and/or perhaps taking enforcement action
Wider remedial action to ensure, where appropriate, that action is taken to prevent a recurrence more widely. This may involve sharing learning, influencing action to be taken, and monitoring progress of action delivery:
- on similar sites operated by other dutyholders across GB
- across industry sectors where learning might be relevant
- within HSE, eg. in relation to intervention strategies and adequacy of relevant guidance
Remedial action may involve a long-term commitment, for example involving significant capital investment or complex management of change. Where such longer-term action is involved you may wish to close the investigation and establish follow-up action, in line with step 4.12 of the investigation procedure.
Identify the relevant law and whether there are any breaches
This objective focuses on identifying relevant legislation and determining whether there has been a breach.
For goal setting legislation it will be necessary to identify the relevant standards/benchmarks against which the dutyholder(s) can be measured to determine whether there has indeed been a breach.
The priority you give this objective will depend on the nature of the incident and it may change as the picture of what happened emerges.
Form a view about appropriate further action using the EMM framework
With the relevant law and any breaches identified, this objective requires that a decision be taken using the Enforcement decision making procedure on what, if any, enforcement action is required.
This will include any action considered necessary in order to control a risk of serious personal injury, or to secure the delivery of improvements to prevent a recurrence.
Where enforcement action is required, you should follow the relevant OG wide procedures.