Incident Reporting & Investigation

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Incident investigation and reporting are important elements in managing visitor safety. We want our visitors to enjoy their experience and return home unharmed. It is essential to learn from accidents and near misses that do occur.

Getting the information, however, is not always that easy. Millions of visits are made each year to sites with free public access that have no staff. Finding out about accidents, learning from them and communicating the lessons is a major challenge.

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• to check whether your risk control measures are sufficient and effective
• it may be a statutory requirement (see page 66)
• it is likely to be a requirement of your insurance policy
• to provide information in case there is a claim for compensation or a need to defend a legal action
• to identify trends in the pattern of incidents. This in turn can lead to improved risk controls
• to measure whether your safety record is improving or deteriorating.

COMMON OBSTACLES TO INVESTIGATIONS

• difficulty in collecting information – this is a major problem for unstaffed sites
• the information provided on accident reports may have insufficient detail
• the condition of the site of the incident can change rapidly, e.g. with weather or subsequent public access; so gather information and take photographs of the site immediately after an incident
• fear of blame – to counteract this, it helps to create a management culture in which staff and visitors are not afraid to report incidents and near misses
• over-complicated reporting systems – introduce simple and clear systems that minimise paperwork
• staff being unaware of the value of the information they supply. It is essential to give feedback and show how things have changed as a result of incident investigations
• visitors may not know whether or how to report incidents.

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Do I need to report an incident?

Every case needs to be considered on its own merits. Take, for example, a cyclist injured and taken to hospital after a fall when cycling in a forest. If the cyclist simply lost their balance on a forest track built for timber haulage it is unlikely that the accident would need to be reported to the enforcing authority. (Although it is good practice to record it.).

If, however, the accident occurred because of a failure on a purpose-made trail provided by the forest owner, reporting would be necessary. The condition of the facility was connected to the injury and the ongoing maintenance and inspection of the trail is a work activity. If in doubt you can always discuss the need to report with the enforcing authority.

Image: (Left) Mabie, Dumfries and Galloway (Right) Balblair, Highland.

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Berrington Hall, Herefordshire

It is important to have a clear process for reporting and investigating incidents. This should include advice on when to involve competent safety practitioners, insurers or legal advisers after a serious incident. You should also consider whether the incident could give rise to media enquiries and how these would be handled.

You must also ensure that the person who investigates an incident has the necessary skills, knowledge and experience.

Many organisations have specific forms to report incidents and record investigations. Often the two are combined. Typically, they gather the following information:

BASIC FACTS

• where the incident happened
• what happened
• date and time
• who was involved
• physical characteristics of the site
• facilities or equipment involved
• activities of those involved
• the weather at the time of the incident (you may also wish to consider details of clothing and footwear being worn at the time)
• the nature of any injuries (actual or potential)
• damage to property or environment (actual or potential)
• what control measures, if any, were in place
• the condition of any control measures.

Do not remove evidence or otherwise disturb the scene. This is particularly important if the incident is likely to be examined by the enforcing authority; but is also necessary to facilitate any investigation.

GATHERING EVIDENCE

Evidence is critical to establish the causes of incidents and should be gathered before any changes are made to the site and whilst it is fresh in people’s minds. Information to be gathered should include:

• photographs or video recordings of the incident/site
• any CCTV recording
• witness statements
• any damaged equipment or infrastructure.

Stick to the facts and avoid giving opinions on fault or blame.

Be careful when asking for statements at the time of the event from witnesses who may be distressed. It might be more sensitive to ask for an address and telephone number and make contact later.

INCIDENT HISTORY

The investigator needs to establish:

• has a similar incident happened before?
• were recommendations made to prevent a recurrence?
• if so, were the recommendations carried out?

CAUSES

Look beyond the immediate cause of an incident to see if there are important underlying reasons. Often there are several interrelated causes. For example, the immediate cause of an incident might be a failure of the infrastructure you have installed. The underlying cause might be lack of maintenance or a failure to inspect it. That may itself have resulted from an underlying cause of lack of training or inadequate supervision.

Take the example of a cyclist injured when falling at a speed bump. The immediate cause of the incident was excessive speed over the bump. The underlying cause might be that the speed bump was not easily seen because of inadequate maintenance. A warning sign might have been obscured by tree growth; paint indicating the bump may have worn off. A deeper underlying cause may have been poor design of the speed bump in the first place. Was the potential risk to cyclists considered? Could a gap for cyclists have been included?

RECOMMENDATIONS

Recommendations are actions to lessen the chances of a similar incident occurring in the future, or to reduce its severity. However, a recommendation could also be made to accept the risk (with the justification recorded) and do nothing. Where recommendations for action are put forward, they should be given a timescale for implementation.

Key Example:

A visitor is injured when falling down steps in an historic castle. The immediate cause of the accident might have been that the visitor did not appreciate that the height of the steps was inconsistent. The underlying cause might have been that the depth of the steps was not obvious because of the contrast between bright sunlight and shade (A).

Another underlying cause might have been the uneven surface of the steps or the lack of information on site hazards at the point of entry. The lack of a handrail might have made the consequences of the visitor’s inattention more severe (B).

Image (L) A (R) B

REVIEW

There should be a review to see if the recommended actions have been taken and to assess whether they were adequate and appropriate. Berrington Hall, Herefordshire.

REPORTING TO THE ENFORCING AUTHORITY

Certain types of accidents to employees and members of the public must be reported to the relevant enforcing authority – this is a requirement in the UK under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR 2013). If a member of the public is killed or is taken directly to hospital following an incident connected to your work you must notify the enforcing authority without delay, most easily by reporting online.

The enforcing authority is usually the environmental health department of your local authority or the Health and Safety Executive in Great Britain; the Health and Safety Executive for Northern Ireland or the Environment, Safety and Health Directorate in the Isle of Man.

In Ireland the Safety Health and Welfare at Work (Reporting of Accidents and Dangerous Occurrences) Regulations 2016 require fatal and non-fatal injuries to a non-employee, arising from a work activity, to be reported to the Health and Safety Authority.

You do not have to notify the enforcing authority in every instance when a visitor is injured on your property and is taken to hospital for treatment. The injury must have arisen out of or in connection with your work or undertaking or the condition of your premises.

Your undertaking may well include the provision of recreation opportunities and access to the countryside for members of the public. ‘Premises’ has a wide meaning. It could be property like a castle, church, stately home, garden or park. It encompasses facilities such as toilets, play areas, woodland walks and car parks. It can include canal towpaths and river banks, harbours and jetties. It includes infrastructure such as roads and footpaths, locks, bridges and tunnels.

Even if you do not need to report an incident to the enforcing authority, you may be required to notify your insurer. You should also always investigate serious incidents.

In Ireland, if you are a state indemnified organisation, you are required to report all incidents to the State Claims Agency.

KEEPING RECORDS

It is a legal requirement (under RIDDOR) to keep a record of any incident reported to an enforcing authority. This must include the date and method of reporting, the date, time and place of the event, personal details of those involved, nature of the injury and a brief description of the circumstances of the incident.

It is important to record all other significant incidents and near misses (even if not reported). The information may be essential to answer compensation claims and deal with legal or insurance concerns.

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DO I NEED TO REPORT AN INCIDENT TO THE ENFORCING AUTHORITY?

Note that the need to report does not necessarily mean that the accident has involved a breach of the law.

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