Learning the lessons

How to respond to deaths at work and other

serious incidents

www.iosh.co.uk/learningthelessons Information guide

IOSH publishes a range of Learning the lessons how to If you have any comments or questions
respond to deaths at work about this guide please contact
free technical guidance. Our and other serious incidents Research and Information Services at
guidance literature is designed This guide aims to help organisations IOSH:
respond to hazardous events, such - t +44 (0)116 257 3100
to support and inform as accidents, cases of ill health, work- - researchandinformation@iosh.co.uk
members and motivate and related violence and dangerous
occurrences. The advice covers PDF versions of this and other guides
influence health and safety fatalities, exposure to life-threatening are available at www.iosh.co.uk/
stakeholders. health hazards and high incidence rates freeguides.
of chronic ill health problems.
The advice also applies to less serious Our materials are reviewed at least
events, especially those with the once every three years. This document
potential for high loss. was last reviewed and revised in
May 2015.
Contents

Foreword 02

Glossary 03

1 Introduction 04
2 Why do you need internal investigations? 05
3 Preparing and planning your response to hazardous events 05
4 Initial response 06
4.1 Accidents and dangerous occurrences 06
4.2 Occupational ill health and exposure to serious health hazards 07
5 Internal investigations 09
5.1 Investigation team and remit 09
5.2 Roles and relationships 09
5.3 The investigation 10
5.4 Information gathered by external investigators 10
5.5 Investigation and analysis techniques 11
6 Competent investigators 12
7 How to avoid common failings in investigations 12
8 Good practice in investigation reporting 13
9 References 14
10 More information 15

Appendices

A Some relevant UK legislation 16
B Legal privilege 18
C Competence checklist 18
D Hazardous event investigation checklist 20

Acknowledgments 21
Foreword

When someone loses Thankfully, for most employers, Steve Watts MSc DPM D.Crim (Cantab)
their life in a serious workers and health and safety advisers, FCIM
work-related incident, work-related deaths are rare. But Assistant Chief Constable
organisations can be preparation and co-operation are Hampshire Constabulary
in a state of shock and key to successful investigations and
disbelief. Invariably, knowing who does what and when
where a death occurs in the workplace can be invaluable. The important issue
or as part of a work-related incident, here is finding out the truth of what
the police on behalf of the coroner happened.
will be involved as part of their duty
to investigate unexpected death. On a This guide tackles a difficult subject
few occasions, this investigation may well and is important to law
need to be more extensive if questions enforcement investigators, managers
of culpability arise. All those involved and internal investigators alike.
at the initial stages of an incident must
be aware of the need to preserve and
gather information and keep everyone
safe. This will allow others to make
well-founded decisions as to what led
to the workers death.

The death or serious lessons are learned for the future. Peter Brown
injury/illness of a Fatal accident investigations are always Head of Health and Work Division
colleague is a cause of very serious, may involve various Health and Safety Executive
sadness and regret and enforcement authorities, and can also
may also raise concerns be lengthy, inevitably raising fears and
among employees about their own uncertainties within organisations.
health and safety at work. Prevention By clearly explaining some of the key
and protection are obviously key, issues and agencies involved, this
but where this hasnt happened, and guide will help internal investigators
someone has been seriously harmed to understand what is likely to happen
or killed, its essential that a thorough and what their role in the process is.
investigation takes place and that

02
Glossary

Body mapping
An information gathering technique that uses a chart with large outline drawings of both front and back views of a
body. Groups of workers who do similar tasks are asked to mark on the chart any parts of their body that are affected
by their work. Colour-coding is often used, for example red for aches and pains, blue for cuts and bruises, green for
illness. The data are used to identify if there are any trends or problem areas associated with particular tasks.

Dangerous occurrence
An undesired event that causes significant damage to plant, premises, equipment or the environment. Dangerous
occurrences dont harm people, but they have the potential to. (The term includes, but is not limited to, items listed
under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013 (RIDDOR),
www.hse.gov.uk/riddor/index.htm.)

Hazardous event
A generic term for an undesired event that causes or has the potential to cause harm or damage, such as serious
occupational accidents, near misses, cases of ill health and dangerous occurrences. Hazardous events include fatal,
major and lost-time injuries, exposure to health hazards, occupational diseases, fires, explosions, accidental releases or
exposures, structural collapses and near misses.

Near miss
An undesired event that doesnt lead to death, serious harm to people or damage, but has the potential to.

Serious occupational accident

An undesired event leading to death or reportable cases of ill health and injury (see Reporting of Injuries, Diseases and
Dangerous Occurrences Regulations 2013 (RIDDOR), www.hse.gov.uk/riddor/index.htm).

Traumatic incident
A critical, undesired, work-related event that causes psychological distress. Indications of the distress may include
flashbacks (re-experiencing the event) or avoiding stimuli associated with the event. Traumatic incidents involve
experiencing or witnessing catastrophic damage, severe injuries, dead bodies or body parts, the death of colleagues,
road traffic accidents, verbal or physical assault, armed raids and hostage taking.

03
1 Introduction

This guide aims to help organisations The guide is aimed particularly at Offered in good faith, this guide isnt
respond to hazardous events, such as employers and health and safety intended as a substitute for professional
accidents, cases of ill health, practitioners. Its not intended as a legal advice, which duty holders should
work-related violence and dangerous practical guide on how to investigate obtain from a competent legal adviser,
occurrences. Weve tailored the advice we refer to other publications that can and we therefore cant accept liability
to cover fatalities, exposure to offer more detailed advice on this. for its use.
life-threatening health hazards and
high incidence rates of chronic ill Weve based our advice on current
health problems. Apart from sections arrangements and regulatory practices
5.2 and 5.4, the advice also applies in England and Wales, although there
to less serious events, especially those are some important legal differences
with the potential for high loss. in Scotland and Northern Ireland.
While the objectives and processes
We outline good practice when a of internal investigation may be
serious event happens, and give similar in other countries, the legal
information on: system and roles of the police and
- why you should hold internal labour inspectorates may well be
investigations different so be aware of the possible
- preparation and planning differences while reading this guide.
- the initial response
- internal investigations: roles, Throughout, weve used the term
inter-relationships, information internal investigator to mean in-house
gathering and techniques investigators or consultants used by
- how to make sure investigators are an employer to investigate serious
competent incidents on the employers behalf.
- how to avoid common failings in We use external investigator to mean
investigations only investigators acting on behalf of
- good practice in investigation the police or regulatory authority, for
reporting. example a government inspectorate.
We dont cover the role of insurers,
although they are also external and
often investigate serious events.

04
2 Why do you need internal investigations?

Serious hazardous events, or those also want assurance that proper Under regulation 5 of the
with the potential for a serious controls are in place to prevent Management of the Health and
outcome, can indicate failures in your similar events. You may also want Safety at Work Regulations 1999,
organisations risk control system and to produce an investigation report employers are required to monitor
need to be investigated. Its important as a legal defence, and this may be and review preventive and protective
to understand why the risk assessment covered by legal privilege. (This measures. This can be achieved by
and control measures didnt prevent issue is not covered in the sections investigating accidents and incidents.
the event and what needs to be that follow, although the term Theres also an explicit legal duty to
done to make sure it doesnt happen legal privilege is briefly outlined in investigate work-related hazardous
again. Investigations also give you Appendix B, page 18). events where organisations operate
the chance to examine how well your under permissioning regimes, such
organisations emergency response There are also legal drivers for as British safety case legislation
system worked, so that you can learn investigation. Arguably, theres an applying to major hazard industries
lessons for improvement. implicit duty in Britain under the Health (except offshore). Additionally, British
and Safety at Work etc Act 1974 for law gives a right to investigate to
Serious events naturally cause employers to investigate work-related enforcers and union-appointed
concern and anxiety throughout hazardous events to prevent them safety representatives. Theres also
an organisation. A thorough happening again and to protect the legislation covering gathering and
and effectively communicated health and safety of employees and disclosing criminal evidence (see
investigation will help everyone others. This implicit duty to investigate Appendix A, page 16).
understand exactly what went wrong is also contained in regulation 3 of the
and whats been done, or needs to be Management of Health and Safety at To get the maximum business
done, to protect people in the future. Work Regulations 1999,1 which requires benefit for your organisation in
Shareholders, investors, clients, a review of risk assessments if there are terms of minimising future losses, an
insurers and other stakeholders will changes, for example an accident. investigation should take account of
the realistic worst consequences of the
event, not just what actually happened.

3 Preparing and planning your

response to hazardous events

When theres a serious hazardous sure you have an investigator whos Your emergency plans should include
event, your management team will be competent and has access to adequate clear arrangements for immediately
expected to act quickly and decisively resources (see section 6, page 12). alerting the emergency services,
in a situation that may be entirely Theres information on preparing for senior people in the organisation
new to them. Its therefore helpful to and planning to manage occupational for example, a director or manager
devise and test a set of emergency hazardous events in BS 180042 and responsible for health and safety and
preparedness plans to cover the in guidance prepared for the railway the person in charge of the site or
various possible types of serious industry3,4 this may also be useful in work affected. In practice, more than
event, such as death, serious damage, other sectors. one employer may be involved, and its
injury and ill health. Your emergency usually the employer in control of the
planning should include appointing premises who should take the lead in
an investigator (or investigation the internal investigation, unless you
team) either specific people or those agree otherwise by contract.
in specific posts. Its vital to make

05
4 Initial response

This section covers the first actions you Usually, an inspector will visit the The person you choose may be
need to carry out when responding scene before letting you start to the same person wholl later lead
to serious accidents and dangerous clear up. In Britain, where theres the internal investigation (the
occurrences (section 4.1), and cases been a fatal accident, the police will investigator), but incident responder
of actual or potential occupational give the all-clear; in cases where and investigator are different roles and
ill health (section 4.2). Where there are no deaths, this will be can be carried out by different people.
appropriate, theyre the same as the done by the relevant regulatory To retain independence and objectivity,
actions that the first police officer must authority. As long as you dont its often best to select a competent
take when they attend the scene of a disturb the scenes and evidence, investigator from somewhere in the
workplace death these actions are and you dont compromise the organisation that has had no direct
listed in the Investigators guide.5 As privacy of people whove been involvement in whats happened.
well as incident-specific actions, you injured, you can take photos, video
also need to decide whether theres a footage or sketches The lead internal investigator will
risk of a similar occurrence elsewhere - make sure key people in the usually be an experienced health and
in the organisation or beyond, and to organisation are told, such as safety practitioner or a senior manager
alert those concerned. senior managers, health and safety with access to competent advice. If
advisers, workers representatives or there isnt someone at this level, you
4.1 Accidents and dangerous communications department should identify another suitable person
occurrences - begin a written record of events at say, a local manager supported
If theres a serious accident or the scenes, including a list of visitors by health and safety adviser who
dangerous occurrence, your first - identify witnesses, including people: can take charge and lead the initial
priority, as the employer, is to involved in or present at the event management (securing the
implement any emergency plan you time of the event scene, preserving evidence, recording
have, including: who may have seen, heard, information) until the designated
- identify the location and extent of smelt or felt something investigator can take over.
the incident scenes relevant
- identify any remaining hazards, who have knowledge of the The people and equipment involved
assess the risks and make the event or circumstances in the hazardous event may be the
scenes safe who can confirm the actions responsibility of several different
- provide first aid if needed and call of others or the data thats employers, and they all may have
the emergency services, including been gathered a procedure for dealing with and
the police and the regulator (in - agree with the police (who normally investigating this sort of event. As
Britain, call the Incident Contact take the lead on behalf of all the each employer will have specific
Centre on 0845 300 9923; in emergency services) or, where interests and concerns, joint internal
Northern Ireland, follow the advice theyre not involved, the regulator investigation is unlikely, although it
at www.hseni.gov.uk/contact-us/ how youll handle communications can save time and duplication if they
report-an-incident.htm) with your workforce, relatives of can agree to share information (see
- secure the scenes you can do this the dead or injured, and the media section 5, page 09).
by taping or fencing off the area or - in co-operation with the emergency
even posting sentries. You should services, make arrangements for The police and the regulatory
also identify, preserve and secure supporting anyone whos been authority (in Britain, usually the Health
any other sites (secondary scenes) affected by the incident (see page and Safety Executive (HSE) or local
or evidence that are separate from 08, Support for employees after a authority) will attend the scene of a
the main scene but may be relevant traumatic incident). fatal accident and may visit the scene
to the investigation, such as control of other serious hazardous events.
rooms, site logs, CCTV footage Your next priority is to authorise Either the police or the regulatory
and software records. If someone someone to look after your interests at authority will take the lead in a
has been killed, you need to know the scene. For serious hazardous events, criminal investigation (whats known
where the body is. If a body has this persons primary role at this stage as taking primacy) referred to as
been moved, you need to secure its will be to work with the emergency the external investigator in this guide.
current location services and regulatory authority,
- prevent disturbance to the accident provide any support they ask for and
scenes, except to avoid more injury make sure the scene stays secure.
or damage, until the regulatory
authority gives its permission.
06
If theres been a work-related death, a description and analysis of physical 4.2 Occupational ill health and
the first police officer to arrive will take evidence from the site). Working exposure to serious health hazards
initial responsibility and control of the together will also help the gathering of People can become ill as a result
scene. However, the police may pass other information, for example witness of their work some time after the
this responsibility onto the regulatory statements and documents. exposure or event. The delay is called
authority at an early stage. Sometimes, the latent period. The length of the
the police and the regulatory authority You shouldnt give out any information latent period depends on the illness
will carry out a joint investigation. about the investigation to third parties and its cause, the amount and length
Work-related deaths: a protocol without the formal permission of the of exposure, and the victims individual
for liaison6 gives details of the external investigator. The media may susceptibility.
arrangements that exist between the expect briefings and updates, so the
police and regulatory authorities in investigating parties should agree a If the latent period is long, its unlikely
England and Wales, and in Scotland. strategy for releasing information. that youll have to act as quickly as
Theres also a circular aimed at Theres detailed guidance on media you would for an accident. In general,
HSE and local authority inspectors, management after occupational youll need to:
which covers liaison arrangements accidents in the Railway Group - determine whether people are
and guidance relating to potential Standards prepared for the rail still being exposed and potentially
manslaughter and homicide cases.7 industry3,4 the advice may also be harmed, and look at what controls
helpful for other occupational accidents could be implemented to reduce
As soon as the initial response is where theres likely to be media this exposure
complete, the internal lead investigator interest. - implement an emergency plan,
should: including anticipating interest from
- take control of the internal If the appropriate authority intends to the media, employees and the
investigation prosecute, they should tell the duty public if the illness is potentially
- set up a link with the police and/ holders concerned as soon as they widespread, for example food
or the regulatory authority to avoid have enough evidence to support poisoning or cancer
impeding any criminal investigation their decision. In these circumstances, - preserve relevant scenes and
remember that the external the rules of the Police and Criminal evidence, for example dust
investigation takes precedence over Evidence Act 1984 (PACE) will apply in extraction equipment, documented
internal inquiries. When the police England and Wales. Northern Ireland risk assessments, health records
are involved, the key contact is the is covered by the Police and Criminal - authorise someone to take charge
senior investigating officer (SIO). Evidence (Northern Ireland) Order 1989, of the internal investigation.
Its important to make contact with and Scotland by the Criminal Procedure
the SIO early on and maintain good (Scotland) Act 1995. Also, if the illness or condition is legally
communications throughout reportable, tell the regulatory authority.
- plan and outline to relevant The external investigators will decide
employees how the internal when the scene(s) of the accident
investigation will be carried out, can be released. At this point, the
noting that the timing may depend lead internal investigator should take
on what the external investigation responsibility for returning the scene to
requires. the sites usual management. This can
only happen when the investigators are
The internal investigation may then satisfied that theyve gathered all the
continue alongside the external inquiry. evidence relating to the accident and
In section 5, we give guidance on the that the site is safe to use. If theres
potentially complex area of liaison been significant damage, it may be
between the two. necessary to appoint a recovery team
to oversee repairs and tests before work
The internal investigator should aim to can start again in the affected area.
work with the external investigators and
find out how much information they
can share with each other. For example,
everyone may benefit from access to
the same forensic report (which gives

07
If youre dealing with a case of acute - securing the scene(s) symptoms or made a complaint. Its
occupational ill health, such as after - agreeing how youll communicate also important to remember that
exposure to asthmagens, allergens and with your workforce, relatives of fears that people have been exposed
toxic or biological agents,* youll need the sick, and the media. to a serious health hazard, and any
to take emergency action thats similar resulting media attention, need
to what youd do for an accident. In The investigation should then continue careful management, reassurance and
other words, you need to put in place as we describe in section 5 (page 09). clear communication. If you identify
onsite and offsite emergency plans, possible cases of occupational ill
which normally include: You should also investigate events health by looking at sickness absence
- assessing the risk and making the where theres a significant risk from trends or other indicators such as
scene safe, including evacuation if physical, chemical or biological the results of body mapping (see
necessary health hazards, such as exposure to Glossary, page 03) and biological
- making sure that first aid has been radiation, excessive noise or vibration, monitoring you should investigate
given where needed asbestos fibres or pathogens. This kind these too.
- contacting the emergency services of exposure should be investigated
and working with them even if no-one has reported any

Support for employees after a traumatic incident

You should provide practical support to employees helpful to give information on symptoms of PTSD and where
immediately after an incident. Things they might need to get support in the longer term, but you need to consider
help with include: how best to pass this advice on. Victims and witnesses
- contacting their families of accidents may not be able to take in extra information
- dealing with the police and investigators immediately after the event, so it may be better to give this
- preparing witness statements kind of help at a follow-up session.
- accident reporting and other paperwork.
In the longer term, you may want to offer evidence-
Its also important for the manager to show empathy,8 and based therapy to someone whos deeply affected, but this
get advice about the normal range of emotional responses isnt appropriate as an immediate response. For anyone
to traumatic events. In Britain, guidance for health still experiencing serious symptoms one month after the
professionals from the National Institute for Health and accident, NICE recommends trauma-focused psychological
Clinical Excellence (NICE) on post-traumatic stress disorder treatment.9 Remember many people not directly involved
(PTSD) recommends watchful waiting in cases with mild in a traumatic incident can be affected and need support,
symptoms that have lasted fewer than four weeks.9 The including investigators. Also, legal cases can take years and
symptoms often disappear by themselves, and the benefits people can have the threat of prosecution hanging over
of intervening in the early stages are unclear. It can be them for a long time.

* In certain countries, some infectious diseases have to be notified to the authorities.

08
5 Internal investigations

This section is about in-house difficult in smaller organisations, but - physical and psychological
investigations. It doesnt cover basic its essential to make sure investigators trauma youll need advice
investigation skills theres plenty of are competent, and this includes from doctors about when you
information on this available elsewhere considering how independent they are can interview people whove
(see section 5.5). Nor does it cover in (see section 6, page 12). suffered serious injury, illness or
detail what external investigators may psychological harm as a result of the
do. You can get guidance from the HSEs 5.2 Roles and relationships event. Waiting for them to recover
website10 on external investigations in Different bodies investigate accidents may delay your investigation. When
Britain, and on the HSEs investigation and cases of ill health for different you do interview them, keep your
procedure for major incidents.11 purposes examples include the questions to the facts and avoid
employer, the police, the regulatory asking them about their emotional
5.1 Investigation team and remit authority and the employers insurer. responses
Internal investigations into serious All investigating bodies should have the - survivor guilt a common
hazardous events will normally need same long-term objective of making reaction where people experience
the skills and time resources of more sure the events dont happen again. psychological trauma is a strong
than one person, so a team approach Nevertheless, as there are different feeling of guilt at surviving or
is usual. In the early stages, when you shorter term reasons for investigating escaping when others havent.
still dont understand the root causes (such as law enforcement, liability Recognising this will help you direct
or sometimes even the immediate mitigation or risk management), people your investigation
causes, it may not be clear exactly may be reluctant to share information. - contractual issues there may be
what resources you need. At this commercial implications which make
stage, it may be enough to appoint an Other people and groups will also someone reluctant to accept (or
experienced line manager as the team be interested in the progress and imply that they accept) liability
leader and an experienced health and results of the investigations, including - insurance issues normally some
safety professional to advise him or her injured or ill staff and their families, of the costs resulting from work-
(see section 6, page 12 for more details other employees, health and safety related death, illness or serious
about team resources and skills). representatives, trade unions, clients, damage are covered by insurance.
suppliers or contractors, and legal and Generally, a condition of insurance
We recommend that you give your medical advisers. As a result, various policies is that the policy holder
internal investigators a written remit issues can affect information gathering shouldnt admit liability, and this
specifying: and sharing, including: requirement is often interpreted as
- the purpose of the investigation - self-recrimination people may an instruction to volunteer as little
- who they should send their initial feel, rightly or wrongly, that they information as possible
report to could have done more to prevent - involvement of law enforcers
- a timescale for producing their the event. If people are reluctant most people caught up in work-
report. to share these feelings with the related deaths and other serious
investigators, it may be difficult to events have little previous experience
At least at the start of their inquiry, get hold of important information of dealing with the police or other
you shouldnt expect your investigators about their actions or knowledge enforcers. They may be unsure of their
to do their normal jobs as well. - self-rationalisation over time, rights and responsibilities, and may be
people may justify to themselves particularly worried about how they
A key role for managers and supervisors what they did or didnt do, and could be implicated in any criminal
is to prevent loss of control and/or alter their memories so that they act which may have been committed.
minor losses escalating into serious no longer accurately recall what Even if theyre not directly involved,
ones so the root causes of serious happened. This subconscious they may be concerned about being
hazardous events are likely to include forgetting of important facts is asked to give evidence in court. As
areas of management and supervisory a primary reason for interviewing a result, they may be reluctant to
deficiency. Thats why the people who witnesses as soon as possible after volunteer information
lead the internal investigation should be the event. Interviewing people
independent of local line management, without delay also helps prevent
but still have a good grasp of the work their memory being corrupted by
being done and the usual controls the passage of time or by discussing
for the relevant hazards. This can be events with their colleagues

09
- legal issues there may be legal 1 collect information 5.4 Information gathered by
restrictions on the evidence that 2 analyse information external investigators
external investigators are allowed to 3 report and make recommendations When theres an external investigation,
share with you for controlling risk in future. you should co-operate with the health
- production and business issues and safety regulatory authority to avoid
youll want to identify the causes of If investigators identify gaps in the committing an offence. Its also good
the event and take action to prevent coverage of their investigation, theyll practice to co-operate with the police
it happening again. But management need to repeat stages 1 and 2. And if to establish what happened. They may
will also want to minimise disruption they fail to carry out any stage of the ask you to provide information about
to their business, limit damage investigation fully, theyll get incomplete the likely locations of key evidence
including loss of reputation if any results and may lose an opportunity to and witnesses, but not to interview
management failings are openly prevent the event happening again. Its witnesses or collect any evidence
reported and restore normal important for investigators to make sure including at secondary scenes until
operations as soon as possible. that: theyve finished and told you that you
They may be reluctant to disclose - the investigation is objective it can. External investigators from health
information if it reflects badly on should have the clear aim of and safety regulatory authorities in the
their organisation identifying the immediate and root UK can require you and other witnesses
- employment issues employees causes of the event (why the event to answer questions at the scene of an
may be reluctant to pass on happened, not just what happened investigation and have a range of other
information because they fear that and where) relevant powers to preserve and take
they, or their workmates, will be - the workforce and any relevant possession of evidence.* The powers of
blamed, and that they could be witnesses, including clients, the police are more limited, unless they
disciplined or lose their jobs. contractors or suppliers, are involved exercise their powers of arrest or obtain
in the investigation and told about a warrant. However, if an offence is
Finding ways to help reluctant people relevant findings suspected, the police or health and
give evidence and help is a key skill for - the recommendations they make safety authorities throughout the UK
a competent investigator (see section 6, as a result of their investigation are can ask you and anyone else suspected
page 12). SMARTT specific, measurable, of being involved in the offence to
agreed, realistic, time-bound and attend an interview under caution.
Investigations by different groups tracked. Normally, line management,
may progress at the same time or at rather than the investigator, decides At times, information may be shared
different times (insurers investigations some of these details (see section 7, and agreed by all parties. However,
frequently occur later), but where page 12) external investigators are unlikely to give
the police or other enforcers are - they review all relevant risk you information theyve collected if they
involved, their investigations must take assessments if they dont do this, plan to use it in a criminal prosecution.
precedence. In the case of occupational theyll seriously undermine the value Once a summons is issued, or the
ill health, the event may actually be of the investigation authority decides not to prosecute, this
a longer term series of events. It may - you publicise the results of the information will be given, as appropriate,
have happened some considerable time investigation, so that the lessons to enquirers if they ask for it.
ago or still be going on. can be learned as widely as possible
as well as giving the results to Where the police or health and
5.3 The investigation those working in the area directly safety regulatory authority interview
All investigators will aim to identify affected, give them to other sites witnesses under PACE, the content
the human factors and organisational doing similar work, and perhaps of these interviews and statements is
failures (root causes) that allowed the your trade association. The UK confidential. Its unlikely that internal
incident to happen. The investigation offshore oil and gas industry has an investigators will be allowed to be
should be a three-stage process: Incident Alerts Database to share present at these interviews. Youll
this kind of information.12 be expected to help identify internal
witnesses to the external investigators,
and to arrange times for interviews.

* Co-operating with the health and safety regulatory authority is covered by section 20 of the Health and Safety at Work etc Act 1974 (or
article 22 of the Health and Safety at Work (NI) Order 1978). The common law offences of obstructing the police and perverting the course
of justice may also be relevant.

10
In Scotland, where reports are In England and Wales, coroners may be 5.5 Investigation and analysis
submitted, statements are the property involved in investigating work-related techniques
of the Procurator Fiscal. Witnesses in deaths. They are independent judicial There are several hazardous event
England and Wales may ask for a copy officers, responsible for enquiring into investigation and analysis techniques.
of their statements and the external the medical causes of deaths that are These range from straightforward
investigators will consider the request. sudden and unexpected, unnatural, approaches such as the HSEs
violent or suspicious. guidance in HSG245, Investigating
Whether they agree to it depends on a accidents and incidents14 (soon to be
number of factors if they think that These can include deaths: superseded by INDG468) to complex
the investigation may be compromised - caused by violence or accidents logic tree systems, which are often
by releasing a statement, they can - in prison or police custody more useful for serious events. Theres
refuse. Witnesses can ask to be - resulting from industrial diseases, no universally applicable method.
accompanied at voluntary interviews such as asbestosis Investigators should have a working
by someone of their choice, and the - during an operation or under knowledge of the available techniques
investigating authority cant refuse anaesthetic and choose one thats appropriate
this without good reason. However, - caused by a medical condition not to the organisation and event. Our
the investigators will consider whether previously recognised or treated by publication Health and safety: risk
the chosen person may influence the a doctor. management (chapters 6 and 20)15
witness or cause a conflict of interest. contains a good practical summary of
Where witnesses are legally required to If there are questions surrounding the techniques and their attributes,
give a statement, they have a right to the cause of death, the coroner may and theres more detail in Root causes
have someone with them. arrange for a post-mortem. If this analysis: literature review.16 You can
shows that the death wasnt due to also get free downloads on specific
External investigators must give receipts natural causes, the coroner will hold techniques, including events and
for anything they take away during an inquest. The inquest is an inquiry conditional factors analysis (formerly
their investigations (police in Scotland to find out who has died, how, when known as events and causal factors
dont have to give receipts, but may and where they died, together with analysis17) and fault tree analysis.18
be willing to). If the authorities take information needed by the registrar See section 10 (page 15) for more
something away, always ask for a of deaths, so that the death can be sources of information on accident
receipt and keep it safe. Make copies registered. The purpose of the inquest investigation.
of any documents that you hand over is not to attribute blame. There are
to investigators, and where possible different arrangements in Scotland, The final choice of which technique to
keep samples of any material the where the role of the coroner is use lies with the lead investigator the
external investigators gather, in case performed by the Procurator Fiscal, who chosen technique should be systematic,
theres a dispute. may ask for a fatal accident inquiry.13 structured, and appropriate for the
See pages 15 and 17 for links to more event. The same technique is unlikely to
External investigators can ask for a information on the role of coroners. be right in all cases.
copy of the internal investigation report
(see Appendix B, page 18). Its important that you give the
investigation team enough resources,
including time, to complete all three
stages of the investigation successfully.

11
6 Competent investigators

Investigation is often a team activity, competent investigator should have As we discussed earlier, competence
with members contributing their own and how to evaluate them. As part of requires a range of skills, experience
knowledge, experience and skill. In your emergency planning, you can use and knowledge. None of these
all cases, the investigation should the factors outlined in Appendix C to qualifications on its own provides the
include input from management and assess the competence of potential competence you need to investigate
the workforce. The competence of investigators. hazardous events you also need
investigators is fundamental to the to have been significantly involved
effectiveness of the investigation. The NEBOSH Diploma and all degrees in a range of minor and major
recognised by IOSH include basic investigations.
The lead investigator and all supporting knowledge about accident, incident
team members should have the and illness investigations. There
analytical, interpersonal, technical and are also NVQ qualifications which
administrative skills needed to carry include basic competence in accident
out the investigation. They should be investigation:
able to form an independent view - NVQ Health and Safety Level 4,
and work well with other people and Element H10 Reactive Monitoring
organisations who have an interest in (primarily for in-house advisers)
the investigation. - NVQ Health and Safety Level
5, Element R3 Investigating
In Appendix C (page 18), we offer Accidents and Ill Health (primarily
some guidance on the attributes a for regulators).

7 How to avoid common failings

in investigations

Organisations can fail to benefit from - not using a recognised analysis If you follow this guidance, together
investigations for a number of reasons. method to move from immediate to with the more detailed information
These often boil down either to not root causes weve referred to, you can make sure
completing the investigation properly - not identifying the root causes, your organisation responds well to
or failing to learn the lessons from the including management failures accidents and incidents. In Appendix
investigation report. Other common - not making sure that the D, theres a checklist to help you avoid
problems include: recommendations are proportionate, the common pitfalls of investigations.
- not appointing a suitably competent address the root causes, and that the
investigator or team action plan is SMARTT
- not involving relevant management - not implementing recommendations
and workforce representatives or reviewing their effectiveness in
- not setting an adequate timetable tackling the identified root causes
for completing the investigation - not adequately communicating
- not giving the investigation enough the findings of the investigation,
resources, including time and including developing ways to make
specialist knowledge sure they stay in the organisational
- not maintaining an independent memory, such as during inductions
and objective view of new employees, including senior
- not reviewing risk assessments as managers, and amending policies
part of the investigation and procedures.

12
8 Good practice in investigation reporting

Your investigation report should have - identify the immediate and root You can get more detailed advice on
the clear aim of preventing a similar causes of the hazardous event making recommendations and on the
incident from happening again. Your - comment on any contradictory or content of investigation reports from
report should: missing evidence, and how this guidance targeted at the rail industry,3
- describe the events that led to the affects the identification of root and also from our book Health and
hazardous event and its immediate causes safety: risk management (chapter 6).15
consequences. For serious events, - give clear, prioritised, cost-effective
where the report is likely to be used and SMARTT recommendations to
in future by people who dont have a address the identified causes and
good knowledge of your workplace, prevent the event happening again.
its important to include clear
photographs and diagrams. You Make sure that someone in the local
should also attach copies of relevant management team is responsible for
documents, and keep the originals in timetabling, tracking and applying the
case of future legal actions recommendations. If disciplinary action
- make sure that names, dates and is needed, it can be linked to the
measurements (in metric) are agreed findings of the investigation,
recorded accurately but it should be done by the
- make a clear distinction between appropriate line manager.
what is established fact and what is
opinion or hearsay

13
9 References

1 Health and Safety Executive. 7 Health and Safety Executive. Work- 13 Fatal Accidents and Sudden Deaths
Management of Health and Safety at related deaths: liaison with police, Inquiry (Scotland) Act. London:
Work Regulations 1999. prosecuting authorities, local HMSO, 1976. www.legislation.
www.legislation.gov.uk/ authorities, and other interested gov.uk/ukpga/1976/14/pdfs/
uksi/1999/3242/contents/made. authorities including consideration ukpga_19760014_en.pdf.
2 British Standards Institution. Guide of individual and corporate 14 Health and Safety Executive.
to achieving effective occupational manslaughter/homicide. OC 165/9. Investigating accidents and incidents
health and safety performance (BS 2007. a workbook for employers, unions,
18004:2008) Appendix K, Incident 8 Rick J, Kinder A and ORegan S. Early safety representatives and safety
investigation. London: BSI, 2008. intervention following trauma: a professionals (HSG245). Sudbury:
3 Railway Group Standards. Guidance controlled longitudinal study at Royal HSE Books, 2004. www.hse.gov.uk/
on incident response planning and Mail Group. (IES 435). Brighton: pubns/priced/hsg245.pdf.
management. GO/GN3518. Railway Institute of Employment Studies, 15 Boyle A. Health and safety: risk
Group Guidance for GO/RT3118. 2006. www.bohrf.org.uk/ management (3rd edition). Wigston:
London: Rail Safety and Standards downloads/traumrpt.pdf. IOSH, 2002 (revised 2012).
Board Ltd, 2008. 9 National Institute for Health and 16 Livingston A D, Jackson G and Priestly
www.rgsonline.co.uk/ Care Excellence. Post-traumatic stress K. Root causes analysis: literature
Railway_Group_Standards/ disorder (PTSD): the management review. HSE Contract Research Report
Traffic%20Operation%20and%20 of PTSD in adults and children in 325/2001. Sudbury: HSE Books,
Management/Guidance%20Notes/ primary and secondary care (Clinical 2001. www.hse.gov.uk/research/
GOGN3518%20Iss%201.pdf Guideline 26). London: NICE, 2005. crr_pdf/2001/crr01325.pdf.
4 Railway Group Standards. Railway www.nice.org.uk/guidance/cg26/ 17 Noordwijk Risk Initiative Foundation.
Group Standard: accident and resources/guidance-posttraumatic- Events and conditional factors
incident investigation. GO/RT3119, stress-disorder-ptsd-pdf. analysis manual. Delft: NRIF, 2004.
Issue 2. London: Rail Safety and 10 Health and Safety Executive. http://nri.eu.com/NRI4.pdf.
Standards Board Ltd, 2010. Enforcement guide (England & 18 US Department of Energy.
www.rgsonline.co.uk/Railway_ Wales) webpage, www.hse.gov. Workbook: conducting accident
Group_Standards/Traffic%20 uk/enforce/enforcementguide/ investigations (Rev 2). Chapter 7:
Operation%20and%20 index.htm; for guidance on 7.3.4 Events and causal factors
Management/Railway%20 investigation priorities for breaches of analysis; and 7.4.1 Analytic trees.
Group%20Standards/ section 3 of the Health and Safety at Washington DC: DOE, 1999.
GORT3119%20Iss%202.pdf. Work etc Act 1974, see www.hse. www.hss.doe.gov/sesa/
5 Health and Safety Executive. Work- gov.uk/enforce/hswact/ corporatesafety/aip/docs/
related deaths investigators guide. index.htm. workbook/Rev2/chpt7/chapt7.htm.
2004. www.hse.gov.uk/pubns/ 11 Health and Safety Executive. 19 Groeneweg J. Controlling the
wrdp2.pdf. Operational procedures major controllable: the management of
6 For England and Wales, see Health incident. www.hse.gov.uk/foi/ safety (3rd edition). Leiden: DSWD
and Safety Executive. Work-related internalops/og/ogprocedures/ Press, 1996.
deaths: a protocol for liaison majorincident/index.htm.
(MISC491). Sudbury: HSE Books, 12 UK offshore oil and gas industry.
2003. www.hse.gov.uk/PUBNS/ Incident Alerts Database (previously
misc491.pdf; for Scotland, see known as SADIE).
Health and Safety Executive. Work-
related deaths: a protocol for liaison
(MISC733). Sudbury: HSE Books,
2006. www.hse.gov.uk/
scotland/workreldeaths.pdf.

14
10 More information

Dekker S W A. The field guide to Health and Safety Executive. HSE Public Health England
human error investigations. Aldershot: statement to the external providers of www.gov.uk/government/
Ashgate Publishing Co, 2006. health and safety assistance. organisations/public-health-england
www.hse.gov.uk/pubns/external
Department of Health. Guidelines providers.pdf. Public Health Wales
for the NHS: in support of the www.publichealthwales.wales.nhs.uk
Memorandum of Understanding IOSH. Consultancy good practice
Investigating patient safety incidents guide: practical guidance on working Scottish Public Health Observatory
involving unexpected death or serious as a competent health and safety www.scotpho.org.uk
untoward harm: a protocol for liaison consultant. Wigston: IOSH, 2012.
and effective communications between www.iosh.co.uk/consultantguide. To find out more about the role of the
the National Health Service, Association Procurator Fiscal in Scotland, visit
of Chief Police Officers and the Health & IOSH. Getting help with health and www.crownoffice.gov.uk/
Safety Executive. London: DoH, 2006. safety: practical guidance on working investigating-deaths/our-role-in-
with a consultant. Wigston: IOSH, 2012. investigating-deaths
European Centre for Disease Prevention www.iosh.co.uk/consultanthelp.
and Control If you need professional help during
www.ecdc.europa.eu Johnson C W. Failure in safety-critical an accident investigation, you can use
systems: a handbook of accident and a health and safety consultant, but
Health and Safety Executive. Competent incident reporting. Glasgow: University you need to be satisfied that theyre
health and safety advice webpages. of Glasgow Press, 2003. competent, suitable and fully insured.
www.hse.gov.uk/business/ www.dcs.gla.ac.uk/~johnson/book. There is an online Occupational Safety
competent-advice.htm. and Health Consultants Register
Norton-Doyle J. Accident management (OSHCR) where you can view individual
Health and Safety Executive. and investigation a practical guide consultants profiles to help you choose
Enforcement guide webpages. These to managing and reducing workplace someone who meets your needs. For
provide information on investigation for accidents. London: GEE Publishing Ltd, more information, visit www.oshcr.org.
health and safety enforcers, for example 2003.
on collecting physical and witness
evidence. www.hse.gov.uk/enforce/
enforcementguide/index.htm.

15
Appendix A Some relevant UK legislation

For background information to legal Part G (Describing what happened) Specific legislation and
requirements, have a look at section 2 of the accident form F2508, which you permissioning regimes
(page 05). must submit for every reportable event, Control of Major Accident Hazards
requires you to describe events that led Regulations 1999 (as amended)
General legislation to the incident, the part people played (See A guide to the Control of Major
Health and Safety at Work etc Act and actions youve taken to prevent Accident Hazards Regulations 1999 (as
1974 a similar event happening again. amended) (L111), HSE Books, 2006.
(See Health and safety regulation: To provide this information, youll www.hse.gov.uk/pubns/
a short guide. Sudbury: HSE Books, need to carry out some kind of basic priced/l111.pdf.)
2003. investigation, no matter how informal.
www.hse.gov.uk/pubns/hsc13.pdf.) Gas Safety (Management) Regulations
Safety Representatives and Safety 1996
Sections 2 and 3 require employers to Committees Regulations 1977 (See A guide to the Gas Safety
do all thats reasonably practicable to (See Consulting workers on health (Management) Regulations 1996
protect the health and safety at work and safety Safety Representatives (L80), HSE Books, 1996.
of their employees or others who may and Safety Committees Regulations www.hse.gov.uk/pubns/priced/
be affected by their organisations 1977 (as amended) and Health and l80.pdf.)
activities. It can be argued that this Safety (Consultation with Employees)
implies a duty to investigate the causes Regulations 1996 (as amended). Nuclear Installations Act 1965
of health and safety incidents, so Approved Codes of Practice and (See Licensing Nuclear Installations.
that future failures can be prevented. guidance. HSE Books, 2009. 2012. www.hse.gov.uk/nuclear/
Section 14 gives the Health and www.hse.gov.uk/pubns/priced/ licensing-nuclear-installations.pdf.)
Safety Commission the right to direct l146.pdf.)
investigations and inquiries; sections Railway Safety Directive. London:
18 and 19 give authority to enforcers; Under regulation 4(1)(a), an appointed Office of Rail Regulation, 2011.
and section 20 gives inspectors their safety representatives function www.rail-reg.gov.uk/server/show/
powers, including 20(2)(d) (or article includes the right to investigate nav.1514.
22(2)d of the Health and Safety at potential hazards and dangerous
Work (NI) Order 1978), which grants occurrences at the workplace (whether This legislation includes some UK
authority to carry out investigations. or not theyre drawn to their attention permissioning regimes in other
by the employees they represent), and words, where a formal safety case
Management of Health and Safety at to examine the causes of accidents or report must be submitted to and
Work Regulations 1999 in the workplace. Regulation 6 gives reviewed by the HSE before a new
www.legislation.gov.uk/uksi/ safety representatives the right to carry facility can be used. Every safety
1999/3242/contents/made out an inspection after a notifiable case must be regularly reviewed and
accident, occurrence or disease, so that updated. The guidance for both duty
Reporting of Injuries, Diseases and they can determine its cause. holders and HSE reviewers on what
Dangerous Occurrences Regulations the safety case should contain covers
2013 the need for a structured health and
(See A brief guide to the Reporting safety management system, including
of Injuries, Diseases and Dangerous procedures for reporting, investigating
Occurrences Regulations (INDG453), and recording incidents, and following
HSE Books, 2013. www.hse.gov.uk/ up on lessons learned from them.
pubns/indg453.pdf.)

16
Ionising Radiations Regulations 1999 Evidence used by police and Coroners system
(See Work with ionising radiation: regulators Coroners and Justice Act 2009
Ionising Radiations Regulations Police and Criminal Evidence Act 1984 (Chapter 25), TSO, 2009.
1999 approved code of practice and (Chapter 60), HMSO, 1984. www.legislation.gov.uk/ukpga/2009/
guidance (L121), HSE Books, 2000. www.legislation.gov.uk/ukpga/ 25/contents.
www.hse.gov.uk/pubns/priced/ 1984/60/contents; and Police and
l121.pdf.) Criminal Evidence (Northern Ireland) This legislation covers the duties
Order 1989, HMSO, 1989. and powers of coroners in relation
Regulation 25 requires duty holders to www.legislation.gov.uk/ to investigating deaths and holding
investigate and notify the authorities nisi/1989/1341/contents. inquests in England and Wales. It
where possible overexposures have also requires that where a senior
occurred, so that they can work out These are the main pieces of coroner provides an organisation
any measures they need to take to legislation that deal with police with a report on actions to prevent
prevent it happening again. powers in the investigation of other deaths, the organisation must
offences. They define arrestable respond in writing.
Railways (Accident Investigation and offences and cover the manner and
Reporting) Regulations 2005 circumstances in which criminal
(See Guidance on the Railways evidence can be gathered in order to
(Accident Investigation and Reporting) be admissible in court; among other
Regulations 2005, Rail Accident things, they require suspects to be
Investigation Branch, 2005.) cautioned before theyre questioned
about an alleged offence.
Regulation 5 requires the Rail Accident
Investigation Branch to investigate Criminal Procedure and Investigations
serious accidents and incidents, or Act 1996 (Chapter 25), HMSO, 1996.
those with serious potential that it www.legislation.gov.uk/ukpga/
decides should be investigated. 1996/25/contents; and Criminal
Procedure (Scotland) Act 1995
(Chapter 46), HMSO, 1995
www.legislation.gov.uk/ukpga/
1995/46/contents.

These cover procedures for disclosing

criminal evidence relating to police
investigations and criminal court
proceedings.

17
Appendix B Legal privilege

This appendix is for information only. Whether documents associated team believes them to be at jeopardy,
If you have any doubt about the with an incident are subject to legal this account may be legally privileged
issues raised here, get competent privilege is a matter for expert legal and marked accordingly.
legal advice. opinion. Simply declaring a document
to be legally privileged doesnt mean Solicitors who want to use privilege may
Legal privilege describes the status of that it is employers who try to use suggest particular wording in a report
some documentary evidence used in privilege where it doesnt apply to protect against unfair incrimination if
legal proceedings. If a document is can be challenged by other parties it becomes disclosable to a third party.
privileged, a party committed to legal in the proceedings. Internal incident Investigators can choose whether or not
proceedings doesnt need to disclose investigation reports arent generally to accept such suggestions and need to
it to the other parties involved. Legal privileged because, although civil and exercise professional judgment to make
privilege can only exist at the point criminal actions may take place, the sure they maintain technical accuracy
where a legal adviser believes that purpose of an internal investigation and objectivity.
the party he or she is defending is report is to describe how and why
at jeopardy (in other words, when the incident occurred and to give External investigators and prosecutors
theyve been cautioned by an enforcer recommendations on how to stop it are legally entitled to ask for a copy of
or have received a civil claim). happening again (as we outlined in a non-privileged internal investigation
section 2). Therefore, the investigators report. However, they may not choose
Examples of possibly privileged objectives arent related in any way to to do this, as they have their own
documents include: legal proceedings that may result from investigation report and also recognise
- correspondence between someone the incident. that demanding access to internal
and their legal adviser reports can damage the value of future
- other information, letters, emails Although we dont generally internal investigations, and breach the
and documents written in recommend it, there may be situations trust between internal investigators and
contemplation of proceedings, ie in which organisations dont conduct their witnesses.
once legal proceedings have begun formal investigations perhaps because
and the parties have hired legal they believe they already know the For more information, see
advisers. cause of the incident. However, if www.hse.gov.uk/enforce/
theyre then taken to court and need enforcementguide/investigation/
evidence for their defence, they may use physical-obtaining.htm, paragraphs
an investigator to provide an account of 3337.
events for their legal team. If their legal

Appendix C Competence checklist

A competent investigator needs: investigation and analysis skills, investigators. You need to be satisfied
- analytical skills independence, legal and technical knowledge that a potential investigator is
sound judgment, clear and - administrative skills in time competent in all the areas covered.
logical thought processes, good management, reporting, evidence You could ask potential investigators
observational skills preservation and recording, to review the issues and demonstrate
- interpersonal skills the ability document drafting, editing. their competence to handle them.
to communicate effectively and
appropriately, good interview Weve created the table on the next Remember its your responsibility
technique page as a checklist for managers for making sure the investigator is
- technical skills effective responsible for selecting and instructing competent.
18
Competence checklist

Yes/no/
Skill area Can the investigator demonstrate that they:
comments
Analytical skills can form an independent, unbiased opinion, not unduly influenced by their
relationship to the organisation theyre investigating?
can stay independent and if necessary criticise peers and/or senior management?
can make meaningful observations, notice relevant environmental factors and
recognise when detail is important?
can gather and analyse information effectively?
can look beyond the immediate causes of an event to identify the root causes?
can identify what evidence is missing and evaluate contradictory evidence?
Interpersonal skills can communicate effectively at all levels of the organisation, and with external
and characteristics parties, such as bereaved relatives, the police and regulatory authority, the media and
contractors?
can use effective interview techniques, including gaining the confidence of reluctant
witnesses?
can manage their own stress when dealing with highly emotive situations?
can use tact and sensitivity when communicating?
can identify barriers to communication and overcome them?
can summarise and explain the objectives, methods, progress and results of the
investigation?
can influence decision-makers?
are assertive enough to express their unbiased professional opinion?
Technical knowledge can use appropriate accident causation theories and associated checklists and analysis
and skills tools?
can use hazard and risk management techniques?
know and understand the activities going on at the time of the event?
can apply and interpret relevant legislation and guidance?
understand the roles and interactions of the police and regulatory authorities?
understand the laws on gathering/using evidence, and other relevant legal issues?
are aware of sources of evidence (eg equipment, sites, people and documents) and
know how to identify, preserve, gather, analyse and record objects and data?
can photograph, video or sketch a scene to an adequate quality, or source such
expertise at short notice?
Administrative skills can manage and/or work within a team?
can work effectively with other professionals (eg medical staff, HR professionals and
lawyers)?
can report their findings concisely and accurately?
can record and preserve evidence appropriately?
Completed by:
Name: Job title:
Date: Signature:

IOSH 2014
19
Appendix D Hazardous event
investigation checklist

Use this checklist to avoid some of the common pitfalls of investigations. We recommend that you complete
it in two parts Part A at the time of the event and Part B when youve finished your investigation.

Part A: Complete at the time of the hazardous event Yes No

Are the investigators competent? (See the Competence checklist in Appendix C)

Have you included arrangements for involving the workforce in your investigation plan?
Have you included arrangements for involving the management in your investigation plan?
Have you set a remit and timescale for the investigation?
Is the timescale realistic can the investigation be completed without rushing or delays?
Have you allocated enough resources (staff, time and money) to the investigation?
Completed by:

Name: Job title:

Date: Signature:

Part B: Complete after the investigation Yes No

Does the investigation report show that the investigator kept an open mind?
Does the report identify what led to the event?
Does the report clearly identify the root causes, including any management failures, of the event?
Have you reviewed all relevant risk assessments in light of the investigations findings?
Are the recommendations SMARTT?
Have you made plans to implement the recommendations?
Have you made arrangements to monitor the implementation of the recommendations?
Have you communicated the recommendations to the staff wholl be directly affected?
Have you considered passing on an anonymised version of the investigation results to relevant trade
organisations?
Completed by:

Name: Job title:

Date: Signature:

IOSH 2014

20
Acknowledgments

Our Technical Committee would like to Thanks also to consultees for their
thank the working party that produced contributions:
this guide: Dr Tony Boyle Consultant, HASTAM
Ian Waldram (Chair) Director, DI Nigel Niven Major Crime
SHEQuality Ltd Department, Hampshire
Martin Allan Managing Director, Constabulary
Martin Allan Partnerships Ltd Dr Jo Rick Programme Director,
Ian Glendenning Consultant, Pragma Institute of Work Psychology,
Consulting University of Sheffield
DS Henry Harper Strathclyde Police Institute of Industrial Accident
Ian Langston Director, Kinaston Investigators
Associates Ltd
Jonathan Russell Director of Health We welcome all comments aimed at
and Safety, Department for Work improving the quality of our guidance,
and Pensions (former Head of Policy including details of non-UK references
Enforcement, HSE) and good practices. Please send your
ACC Steve Watts Hampshire feedback to Research and Information
Constabulary Services at IOSH:
Richard Jones (Administrator) Head t +44 (0)116 257 3100
of Policy and Public Affairs, IOSH e: researchandinformation@iosh.co.uk

21
IOSH IOSH is the Chartered body for health and safety
The Grange professionals. With more than 44,000 members
Highfield Drive in over 120 countries, were the worlds largest
Wigston professional health and safety organisation.
Leicestershire
LE18 1NN We set standards, and support, develop and
UK connect our members with resources, guidance,
events and training. Were the voice of the
t +44 (0)116 257 3100 profession, and campaign on issues that affect
www.iosh.co.uk millions of working people.
twitter.com/IOSH_tweets
facebook.com/IOSHUK IOSH was founded in 1945 and is a registered
tinyurl.com/IOSH-linkedin charity with international NGO status.

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Safety and Health
Founded 1945
Incorporated by Royal Charter 2003
Registered charity 1096790 FS 60566