January 2017 Liz Hunter 020 3028 3369 HSE Inspector of Health and Safety Lizhunterhsegovuk AIMS Accident Investigation Management System Form of Fault Tree Analysis for complex investigations ID: 561751
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Slide1
Investigation processJanuary 2017
Liz Hunter 020 3028 3369
HSE Inspector of Health and Safety
Liz.hunter@hse.gov.ukSlide2
AIMS - Accident Investigation Management SystemForm of Fault Tree Analysis for complex investigationsEstablish key events & conditionsDevelop potential lines of enquiry & queries
Identify benchmarks & gap analysis (legal compliance?)
List significant missing controls
Identify latent & root causes
Determine seriousness of non-compliance & take appropriate enforcement actionSlide3Slide4
Electrocution accident 08/12Slide5
Stringing new conductors Slide6
Protection against induction riskSlide7Slide8
Key EventsDeceased made path to earth for an induced charge (up to 275kV) via earthed metal tower Re-stringing work started without sufficient earthing to create a protected section of line
Inadequate PTWs were issued by SHETL & were accepted by the Norpower teams
The Beauly to Dounreay Project was initiated by SHETL without adequate governance systems to implement SSE’s Operational Safety RulesSlide9
Latent & root causesLatent: a) Lack of monitoring of the implementation of the OSRs by SSE/SHETLb) It was not culturally acceptable to challenge permits issued by SHETL SAPs
c) Individuals did not follow established procedures
Root:
A lack of leadership from the persons responsible for implementing the
OSRsSlide10Slide11Slide12
Craig Services & Access Limited; Donald Craig; J M Access Solutions LtdBizzochi KJF
430 MEWP used to remove safety netting
CSAL & Mr Craig (manager) - failed to maintain MEWP & no TETs
JMAS – Inadequate weld repair done instead of replacing 3
rd
boom of jib boom
Platform fell 28m when repair buckled
Gary Currie died and & another man was seriously injured on 20
th
June 2012Slide13
Found guilty after 16 day trialBoom first buckled in 2011 – no investigation Manager Donald Craig was jailed for 2 years because he deliberately hired out a damaged MEWP & lied about the type of repairs done
Hire company
CSAL
was fined £61,000 for LOLER, PUWER & HSWA offences
JMAS
(carried out repairs to MEWP) were fined £30,000 under HSWA
Sherriff Colin’s sentencing statement:
http
://www.scotland-judiciary.org.uk/8/1712/HMA-v-Craig-Services-And-Access-Limited--Donald-Craig-and-J-M-Access-Solutions-LtdSlide14
Useful linksNew CD Sector Plan http://www.hse.gov.uk/aboutus/strategiesandplans/sector-plans/construction.htm
HSE’s investigation procedure
http
://www.hse.gov.uk/foi/internalops/og/ogprocedures/investigation
/
Guidance on accident & incident investigation
http
://
www.hse.gov.uk/pubns/books/hsg245.htm