Investigating accidents and incidents
Posted on: 20/10/16
Last month Merlin Attractions Operations Ltd was fined £5m for the Smiler Accident. Many lessons can be learnt from this terrible event, and one of them relates to proper accident and incident investigation.
The internal investigation is reported to have blamed ‘human error’. Yet the Company pleaded guilty and the prosecution expert outlined failings covering risk assessment and safe systems of work relating to Merlin’s management of the significant human intervention required in running the ride which fell short of the required standard. In sentencing remarks the Judge also noted a “willingness to blame its employees when the fundamental fault was that of the company.”
Accidents are usually the result of many elements coming together and interacting in a complex way. They can be listed under the headings of ‘immediate causes’, ‘underlying causes’ and ‘root causes’. Human error is often an underlying cause, but root or initiating causes are almost always organisational failings or the absence of good management systems. This is the reason why litigation solicitors often ask for relevant general risk assessments and training matrices, before anything else.
As well as GRA’s and training, we find a lack of supervision, no safe systems of work, poor maintenance and weak isolation procedures figure frequently.
For further reading, HSE Publication HSG245 ‘Investigating accidents and incidents’.