8.0 Operation

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8.9 Accident and Incident Investigation

N.B. This page is being updated to include content for ISO 45001. Until then, the guidance on this page is broadly still relevant to the new requirements.

Analysis of accident reports suggests that many accidents are related to breakdowns in areas such as training, competence, planning and implementation of tasks, maintenance of equipment etc. The organisation needs to put in place systems which enable the capture and evaluation of non-harm events, so that appropriate corrective and preventive actions might be implemented, which either prevent occurrence or recurrence of the events.

There also needs to be robust systems in place to ensure that accidents are adequately investigated and appropriate lessons are learned. ISO 14001 and OHSAS 18001 both require the organisation to put in place procedures to respond to environmental and safety related non-conformances. The definitions given in OHSAS 18001 are helpful in understanding the differences in terms, but put simply, this clause addresses the need to manage things that either could have gone wrong or actually have gone wrong.

The procedures need to ensure that proper control is exercised over the reporting and investigation of accidents, incidents and non-conformances, that any immediate actions are put in place, and that any longer-term corrective actions are initiated and completed. The procedures need to define responsibilities for those involved at all stages of the process. The system needs to take account of injury or damage to employees, visitors, contractors and members of the public, as well as looking at property damage. There needs to be a thorough investigation of all incidents, so that the root causes of the problem may be properly understood.

Data needs to be gathered and records maintained of all stages in the investigation process. It is vital that relevant corrective action be put in place to address problem that have arisen. This action should be reviewed through the risk assessment process prior to implementation; after all, the intention is not to make an unsafe situation worse! But it is vital that unsafe situations are made safe as soon as practicable, which means that corrective action may take place in a number of phases with immediate action to prevent further harm, and medium or longer-term action, dependent on the programme needed, to prevent recurrence of the issue.

A formal system to implement preventive actions is also needed, using data gathered during audit and safety tours, or associated with changes of materials, processes or equipment etc. Again, proper records need to be taken of any preventive actions put into place, and they should of course have been subject to risk assessment. All non-conformances need to be classified and analysed on a regular basis, so that the organisation may understand how effective the management system is proving to be.

The analysis should include such things as accidents, injuries, lost time, ill-health absence, absenteeism, types of damage etc. The results of the analysis need to be communicated to all relevant interested parties. This is particularly the case where the organisation is active at a number of sites or in a number of countries, where the spreading of ‘learning opportunities’ may be more difficult.

  1. Corrective and preventive actions are not closed-out, or there is no objective evidence of close-out;
  2. Inconsistency of actions throughout the organisation;
  3. Lack of communication about issues;
  4. The mechanism for collecting information on near-misses is weak or non-existent;
  5. Lack of awareness;
  6. Inadequate investigation of incidents;
  7. Poor close-out of identified actions;
  8. No review or evidence of review of risk assessments;
  9. Corrective actions not subjected to risk assessment.

More information on PDCA

ISO Navigator Pro™ Main menu Quality Management Principles (QMPs) ISO Navigator Main menu
 

Planning

4.1 Understanding Context 5.1 Leadership and Commitment 6.1 Address Risk and Opportunity
4.2 Interested Parties 5.2 Policies 6.2 System Objectives and Planning
4.3 Determining Scope 5.3 Roles, Responsibility and Authority 6.3 Planning for Change
4.4 Management System Processes    
 

Doing

7.1 Resources 8.1 Operational Planning and Control 8.6 Release of Products and Services
7.2 Competence 8.2 Requirements for Products and Services 8.7 Non-conforming Outputs
7.3 Awareness 8.3 Design & Development of Products and Services 8.8 Emergency Preparedness and Response
7.4 Communication 8.4 Control of Externally Provided Products and Services 8.9 Accident and Incident Investigation
7.5 Documented Information 8.5 Product and Service Provision  
 

Checking and acting

9.1 Monitor, Measure, Analyse and Evaluate 10.1 General
9.2 Internal Audit 10.2 Non-Conformity and Corrective Action
9.3 Management Review 10.3 Continual Improvement

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