Accident Investigation -
2 Day Course
This course aims to give investigators competence to be able to establish the facts and give investigators competence to be able to apply a conducive system that prevents re-occurrence.
At the end of the course delegates will have an appreciation of:
Why accident investigations should be carried out.
How to carry them out effectively.
The relevant legal health and safety requirements to carry out investigations.
The people who may be involved.
How to structure an investigation to maximise information gathering and how to analyse findings to identify causes and determine where responsibility lies.
How to write a good investigation report.
Module 1 – Control Measures, Barriers and Human Failure
Expected Module time 45 minutes
This module is designed to demonstrate to candidates how a consecutive failure in controls / barriers will result in catastrophic failure. Information will be given that demonstrates the different types of controls in place and refers to the Accident Investigation “Trilogy”
1 – Identify the barrier in place
2 – Identify how it failed
3 – Identify why it failed
As 90% of barriers that fail are due to the fact that “Human Failure” is present, the second part of the module concentrates on the different categories of Human Failure and how these are categorised in the RSSB Generic Error Modelling System (GEMS).
Candidates will need to demonstrate the correct categorisation of Human Failure.
Module 2 – Immediate and Underlying Causes
This session concentrates on the possible conclusions and where they feature in the sequence of events. It is much easier for individuals to concentrate on the theory that there is one immediate cause, however there may be several underlying causes. Candidates will need to demonstrate that they can “separate” immediate and underlying causes. Emphasis will be teaching candidates to use the “Why/ Because” method.
The immediate cause – The last thing to happen prior to an accident or incident taking place.
For example – Accident > Person drilling into wall receives an electric shock causing them to fall and receive injured shoulder.
Immediate Cause > Person has come into contact with live electricity
Underlying causes – The precursors to the immediate cause, can be several in number and will ultimately be formed of one of three influencing factors:
For example – Immediate Cause > coming into contact with live electricity > underling causes:
Why did the person come into contact with live electricity? Because the person did not test the system.
Why did the person not test the system? Because the person did not have his testing equipment.
Why did the person not have his testing equipment? Because he forgot due to rushing
Why was he rushing? Because the job had been planned badly
Why was the job planned badly? Because the organisation does not have competence in this area
Why – Because – Why – Because etc.
Module 3 – The Investigation Process
This module gives practical guidance to candidates on where the investigation process sits in legal terms and what the purpose of an investigation aims to achieve. This session also aims to demonstrate to candidates where the specific types of investigation sits in the overall hierarchy. A description of the requirements of Railway Group Standard GO/RT3119 will include:
The Judicial or HSE Led Enquiry
The RAIB led investigation
A Formal Investigation led by Network Rail / Railway Undertaking A Local Investigation led by Network Rail / Railway Undertaking
A Preliminary / Initial Investigation or other
All candidates will need to demonstrate they are aware of the time limits involved to complete each process and how to interpret Appendix A/B of GO/RT3119 – Sept 10.
In addition to the above it is important to note that this session will include a detailed description of the MRE Internal Processes.
Module 4 – Evidence Gathering and the Sequence of Events
The module will describe the key components of:
Non – Perishable Evidence
Candidates will be tutored on the systematic criteria for evidence gathering, maintaining a safe site at the same time. The process will be described in full and candidates will be given “sample evidence” to test their interpretation of what will constitute good and bad evidence.
Candidates will also be given examples of how to use a “Time Line” to establish the “Sequence of Events” when putting together their investigation report.
Module 5 – Conducting Interviews - Theory
A key component of the Investigation Process, candidates will be given coaching on the techniques that can be adopted when conducting interviews and also guidance on creating the correct environment for conducting interviews.
Candidates will need to demonstrate an understanding on the four critical components of the “Open” question process that includes getting Interviewees to explain:
Roles and Responsibilities
In addition to this the 8 essential elements of an interview will be tutored.
Recordings of good and the not so good will be shown and guidance on how to counteract these situations will be practised.
Module 6 – Managing an Investigation Meeting
This session is designed to give the candidates information of how to set up an investigation meeting taking into account:
Module 7 – Actions and Recommendations
This module is designed to give candidates some skills to produce good Action Plans and Recommendations and to know the difference between them. Exercises will include a test to see if candidates can spot the difference between accepted and rejected recommendations.
Production of Action Plans will follow the S.M.A.R.T Criteria taking into account:
Specific – Who do they apply to, who is carrying it out, what is being carried out.
Measurable – How do we measure effectiveness – assessment, inspection, audit etc.
Achievable – Are they fit for purpose and what are we trying to measure
Realistic – We can do miracles, but the impossible takes a bit longer
Time-scaled – Making sure that the right time limit is consistent with achievable targets.
Module 8 – Producing the Report – Theory
This session gives guidance to candidates on what is acceptable in a report and how to structure it, for example:
Using correct vocabulary
Deciding what the reader understands
Graphics and Maps
Do’s and Don’ts
Module 9 – Managing an Investigation Meeting - Practical
Divided into 3 parts this is where the investigation of a particular scenario commences and the lessons from module 6 will be practised. Candidates will be separated into groups of 4. They will then be supplied with the following information to conduct an investigation meeting that includes:
Brief details of the selected scenario
Choice of 6 pieces of evidence from a possible 14
Further choice of 4 additional sources of evidence
Candidates will then need to make a decision on who they will need to interview as part of the process. This module will be carried out in group format, however all candidates will be assessed individually taking into account their understanding of the process and their direct involvement in the sessions.
Module 10 – Conducting Interviews – Practical
This is the penultimate session where the Investigation Panel have decided who to interview and will have an opportunity to conduct either 1 x 40 minute interview or 2 x 20 minute interviews. The 8 essential stages of an interview will be put into practice and candidates will be assessed on the use of these.
Module 11 – Producing the Report – Practical
The final session; where each individual team will produce a report that is a result of all the previous 10 sessions. A report will be produced for each group and will be the result of a team exercise. Groups will have 2.5 hours to complete the report inclusive of Action Plans and Recommendations and will present their findings to the other groups.
Upon successful completion of an assessment candidates will be awarded a certificate from The QSS Group.