Accident Investigation Report: Health and Safety in the Workplace

This report presents a detailed accident investigation, focusing on health and safety in the workplace. It begins with an introduction emphasizing the importance of employee safety and the legal framework in the UK. The main body of the report analyzes the accident, identifying immediate and underlying causes such as carbon monoxide poisoning, lack of training, and poor communication. It delves into the root causes, highlighting negligence by both the company and the deceased, and proposes a five-step model for root cause analysis. The report provides immediate and long-term recommendations to prevent recurrence, including risk assessment checks, implementation of a health and safety management system, and employee training. It also outlines an action plan with specific steps, goals, and monitoring strategies. Finally, the report addresses the company's legal duties and the responsibilities of the individuals involved. The conclusion summarizes the key findings and emphasizes the need for proactive measures to ensure workplace safety. The report draws from various sources and legal frameworks to provide a comprehensive analysis.

Accident
Investigation

Contents
INTRODUCTION.......................................................................................................................................3
MAIN BODY..............................................................................................................................................3
CONCLUSION.........................................................................................................................................17
REFERENCES..........................................................................................................................................18

INTRODUCTION
Every business which functions with the employees is required to safeguard the safety
and health of the employees that are associated with it. This must be the paramount
priority of the business. The employment laws in United Kingdom have been designed
to ensure that rights of the employees are safe against any exploitation. There are
various legislation under the ambit of employment laws which also includes health and
safety. This area also covers many statutes which place duties on both employer and
employees to ensure that all health and safety measures are taken in the company (Lay
and et. al., 2017). It is important that employers must look after the well-being of its
workforce in order to ensure their loyalty and productivity. This project shall cover the
report on accident investigation relating to health and safety of employees.
MAIN BODY
The report on accident investigation shall cover the following points-
1.1 The immediate and underlying causes of the accident.
• Intoxication with carbon monoxide.
• Dismissal of warning sign / message “Keep this door open when using the
generator”. According, to Mr James Collinson “It has been bitterly cold for
the past few nights, which might be why Tom decided to close the door”.
• Use of equipment producing fumes, from burning of hydrocarbon products
without adequate ventilation or extraction and other protective measures
specified under COSHH EH/2005. Limits should be established as
indicated “MDHS14/4 General methods for sampling and gravimetric
analysis or respirable, thoracic and inhalable aerosols”.
• Accordingly, to Mr JC “I never felt ill due to the fumes. I have never
received any training or instructions in relation to the use of generators,
and I have not seen the instructions for the generator that was in use”.

Reviewing the Risk Assessment, I could not find any reference about use
of the generator and risk of being exposed to fumes.
• Lack of training/refresh courses and risk assessment for using adjacent
equipment, Mr JC is saying “I have never been visited on site by the boss
in all the years I have worked here; When I first joined, we undertook a
course that dealt with the legalities of being a security guard”.
• Poor communication ignoring the procedures “I have never seen a risk
assessment for this site or generally for our jobs. We are supposed to
check in every hour, but in reality, this doesn’t happen. Control will call us
maybe two or three times in each shift”.
1.2. Root causes of the accident
The main root cause of this accident was the negligence of the company as well
as the deceased person. The company has failed to take the risk assessment of the
generator which has resulted in negligence by the deceased person by not having
adequate ventilation when running the generator. Moreover, the generator must be
placed at open area rather than keeping it up in the room. The company must provide
adequate training to employees to using the generator and also the risk associated with
it must be communicated to each employee so that they can take necessary
precautions of avoiding such accident. As the risk assessment was done years back, it
is the duty of employer to conduct regular and timely risk assessment so that necessary
precautions can be taken to mitigate it.
The root causes can be prevented by the company by ensuring that it conduct
the risk assessment regularly and also must ensure that it provides timely training to the
employees for every machinery which is being installed for them so that they can learn
all its procedures to run it effectively. This will also help ensure that it hazardous effects
must also be communicated to them so that they do not conduct any negligence when
using it and ensure all steps are taken to prevent any harm from it.
Root causes analysis

There is a five step model which helps in analyzing the root causes. It helps in
determining the cause of problem. In context to the case study, it is discussed below-
 Realize the problem- It is very important to identify the problem initially so that
the company can figure out want went actually wrong. In relation to current case
study, the root cause of the problem was no adequate health and safety
measures taken while operating the generator.
 Collection of data- After analyzing the problem, it is important to collect the
data by taking opinion of people, employees who deal with such type of problem.
In context to the case scenario, the company must begin to take feedback from
other workers who are in similar work environment so that their perspective can
be used to eliminate the root cause of problem.
 Identification of causal factor- This involves reconstructing the timeline of
events. In respect of case scenario, the company must identify the causal factor
such as any action taken or lack of action that resulted in accident. Herein the
lack of action led to the accident.
 Drawing conclusion- after above mentioned each step, the company must draw
the conclusion by assembling all information. In the case scenario, the company
failed to provide adequate training to employees, especially Tom which led to this
accident.
 Implement changes- In this step, the real problem is identified and now is the
time to implement the solution in order to avoid future accidents. In context to
case scenario, the company can implement sufficient solution such as training to
employees, safety measures, etc. so that such accidents can be prevented
(Coulson, 2018).
2 Any immediate recommendations to prevent a recurrence.
• Check if risk assessment is suitable and sufficient, risk control measures
applied accordingly, if not, requires urgent action. All the personnel shall
undertake a training/induction. Reassess all the sites risk assessments for
compliance. The company must ensure that it take risk assessment before

deploying any machinery such as generators so that the employees can
get to know any risk associated with its application.
• Check if an H&S management system is in place and applied, if not, then
shall be discussed and initiated at the executive and management level.
Clearly specifying who will be in charge with regular checking and how
often, an electronic recording system to monitor each employee report,
and reports regularity to be enforced and checked all the way to the
highest level nominated. Regular H&S audit required to check the system
in place and improve where needed (Gul and Ak, 2018). This will help the
security company to take the report of employee’s duty being fulfilled or
not.
• Check if employees delegated to undertake the risk assessment, has the
required training or experience, if not training sessions or qualified
personnel shall be brought on board. For instance, Bill Lutan must make
sure that he is trained enough to take risk assessment for security guards
so that there is no harm or danger caused to them.
• Check if training provided cover the use of equipment supplied, if a
refresher course provided for the above, moving to new site or change of
circumstances. Otherwise, more comprehensive training and CPD
program covering a vast area of circumstances should be undertaken.
• Check if the employee complies with the H&S system in place.
• Checking if the employer has complied with HSE. Recommendations in
regards with, “The Management of Health and Safety at Work Regulations
1999, under section 5, it provides that each employer should give effect to
the arrangement which are appropriate by giving regard to size of its
company and the nature of activities that are undertaken in it so that the
planning, organizing, monitoring and controlling is done of protective and
preventive measure. Any every employer who employs more than 5

workforce is required to record such arrangement.( Kelloway, Nielsen and
Dimoff, 2017)
3.1 Any longer-term / management actions to be taken - let’s look at the big
picture here. You should include a separate section on any issues with our safety
culture.
• H&S policy document shall be reviewed,
• Display the employer commitment towards H&S.
• Statement on general Policy of H&S.
• Responsibilities of relevant person for the specific activities to ensure
compliance with H&S and regulations.
• Reducing the financial losses arising from avoidable unplanned
events.
• Taking responsibility that the accidents, incidents and ill health
resulted from failings in the management control and these are not
necessarily the liability of workers.
• Recognizing that the improvement of supportive environment of a
health and safety is important to attain reasonable control on risks.
• Allocating resources to control and support quality initiative.
• More involved employees, ex. a bonus scheme for reporting H&S
issues, show you care about employee’s wellbeing and engage them
in teamwork (Ding and et. al., 2021).
• Highlighting the importance of protective measures and safety
metrics,
• Every company is different so the metrics must be installed in order
to achieve needs of specific program.

• Employer shall use the right control measures like assessment,
judgement, guidance, and experience.
• Signage to keep reminding about the importance of safety at work to
everyone (Valoriani and et. al., 2020).
3.2 Action plan for the above stated recommendation
It covers many steps which are to be undertaken in order to produce a valid
action plan. These include the following which must be followed by the security
company in preventing any accident of this or similar type.
Set goal Steps to be
followed
Prioriti
ze
steps
Set
milesto
ne
Resourc
es
needed
Visualiz
ation
Monitor,
evaluate
and
update
To
ensure
health,
safety
and well-
being of
employe
e in the
company
especiall
y the
security
guards..
 The
company
must firstly
review its
existing
policies on
health and
safety so
that they
can deploy
sufficient
measures to
protect the
workers.
 Then must
identify the
necessary
Then it
must
prioritiz
e its
steps to
ensure
well-
being of
employ
ees by
making
good
policy
of H&S
which
can
involve
The
mileston
e shall
be to
minimize
the risk
and ham
to the
employe
es and
setting
standard
s of
safety.
The
organizati
on shall
be
required
with
financial,
human
and other
resource
s to
implemen
t this
action
plan.
Then
the plan
must be
visualiz
ed
thoroug
hly and,
if any
change
is
needed,
it must
be
made.
The plan
shall be
monitored
by using
the
benchmark
ing method
wherein
the
standard
will be set
and the
actual
performan
ce shall be
compared
with plan

changes
which are
required to
be made
with hanging
time and
need in the
organization
.
 There must
be proper
instructions
affixed near
the
hazardous
machinery
so that the
worker can
read it
before using
and take
necessary
measures to
avoid any
accident.
 Then it must
appoint the
relevant
person who
must be
accountable
training
measur
es.
so that any
loophole, if
identified,
must be
closed with
immediate
effect.
The
monitoring
of plan
shall be
done in
every 3
months.

for the H&S
policy.
 Then it must
place duties
on employer
and
employee to
take all
necessary
steps to
prevent any
harm or
danger to
people.
4. What exactly are the company's legal duties in relation to this accident? What
about the duties on the individual involved or his manager?
 Employees duty as specified at section 14(1, 2), have not being met, using
equipment untrained and not reporting this to the employer.
Under section 14 of the “The Management of Health and Safety at Work Regulations
1999, the duty of employer is provided which states that any employee who is given the
machinery, dangerous substance, equipment, or other things, the employer must make
sure that proper training is given to the worker as to how to use it and also instruction
must be given to him as to how to use it. On other hand, the employee must also inform
its colleagues and employer about its responsibility for safety and health of other
employees. It must include informing about the wok situation in which the work is to be
done and its immediate harm and danger to the H&S of employees. Secondly, any
matter which represent shortcoming in protection arrangement of employer in relation to

activity of undertaking and which is not yet reported to employer or other workers.
(Sheldon and et. al., 2020). If the employer has not complied with this duty, there is
legal contravention by employer and he/ she will be liable to the penalty.
In context to current scenario, the employer failed to provide relevant instruction
to guard as to how to operate he generator and training was also not provided to him.
Moreover, it is the legal duty of employer to orally communicate all instruction and write
it down the instructions near the hazardous machinery so that the employee can
oversee it every time. In this, the written instruction was placed but no training or oral
instruction was given. The employer failed to take necessary measures such proper
notice about instructing the use of generator, no proper training given to employees, etc.
which results in contravention of law and is a criminal offence which may lead to fines
and imprisonment.
According, to The Management of Health and Safety at Work Regulations 1999,
section 3(1(a), 3(b)); 10(1(a, b)); 13(1, 2, 3), the employer has not met the
recommendations.
Under section 3 of the said legislation, the employer must make assessment of the risk
which is exposed to the employee while they are at work and that assessment must be
reviewed by employer who has made it. (Yanar and et. al., 2020).
Herein, the employer has not conducted the risk assessment which resulted in
the harm caused to Tom, thereby leading to its death. It is a duty of an employer to
conduct timely risk assessment to avoid such accident. Non- compliance with such duty
may result in criminal offence.
Under section 10 of this law, the employer is duty obliged to provide the information to
employee regarding the risk associated to its health and the protective and preventive
measures to avoid it.
In context to this legal duty, the employer failed to communicate with Tom about
any information relating to risk associated with generator in the closed door and what