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                                                          HSG245: A Four Year Survey

This summary of selected points from the HSG 245 Survey is intended to inform members pending incorporation of relevant parts into the ‘IIAI Ten Year Study’ (1998-2008).



Research Comment.

Executive Comment.



Research Comment

Industry appears not to have embraced HSG 245. Accident investigators working amidst adequate and well maintained management systems report a reluctance to advocate its method. A number of principal accident investigators reported that employers and insurers were concerned over the nature of the files that HSG245 accident investigations produce; the view being that if HSG 245 were followed to the letter that the file would secure a prosecution, regardless of circumstance and causal findings.


Whilst the same accidents are indeed happening ‘again and again’, qualified accident investigators felt that publications like HSG245 were steering industry away from the real issues; issues that had to be acknowledged before they could be tackled. The general concern from the survey was that HSG 245 could be a counter productive and ineffectual approach for many Organisations to use.


If HSG245 can be described as a model then it is one built on unsubstantiated notions of  causation. All of the lead accident investigators surveyed considered that the diagram of the ‘dominoes’ in HSG 245 presented a potential bias since the models upon which it is based are ideals rather than theories. That said, all agreed that models of causation such as those by Bird, Weaver, Adams and Reason had proved invaluable in workplaces where management needed to be focused. However, that focus has long been an obsession driven by an inability and reluctance to leave its safe confines or contemplate looking beyond it; evidence from international industrial research, HSE studies and Contract Research Reports is contrary to the notion that management failures cause most, let alone all, accidents.


HSG245’s major 'design flaw’ is that it needs little or no manipulation to arrive at a ‘finding’ of management failure as cause; regardless of circumstance and adequacy of controls. It is capable of doing this despite the existence of some other cause; one that is often left unaddressed, ready to strike again. The HSG245 type of accident investigation does tend to produce numerous ‘root causes’ for a single accident but, no evidence that these have been properly arrived at, tested or verified.


This ‘flaw’ is largely attributable to terminology and definitions. Root Cause is a systems term, complete with its own definitions and tests; it cannot be sought during an accident investigation and does not lend itself to traditional health and safety usage. Nonetheless, its use in health and safety circles over the years has become synonymous with Underlying Cause and, in that respect, the two terms mean one and the same. However, HSG 245 attempts to separately define them, with effect that there is now a confused, ill-defined and additional focus on management failures.


The attempt to separately define the terms was unprecedented and the result is an obvious and foreseeable inability to provide coherent definitions, examples or justification. HSG 245 defines Underlying Cause as “the less obvious system or organisational reason for the adverse event happening” and “Unsafe Acts”. Whilst this definition would be acceptable with appropriate expansion and clarification, the combined effect of terms and definitions in HSG245 is that untrained accident investigators default to label all instances of unsafe acts and errors as management failures.


The regular use of the words ‘contributed’ and ‘condition’ in HSG245 has lead to extensive labeling of irrelevant matters as being Root Causes. These practices tend to be supported and 'justified' by untrained accident investigators; many of whom believe, ahead of their investigations, that the accident in question will have had multiple causes; and/or those whose training has pre-conditioned them regarding cause. Confirmation bias and hindsight bias were found to have considerable roles.


The highest number of reported difficulties came from direct entry members (Associates and Associate Members) whose only form of training at the time had come via NEBOSH or IOSH courses. CRR 344/2001 also found that the majority of ‘accident investigators’ utilised internally by industry have only had ‘generalised health and safety training such as NEBOSH or IOSH courses’.


The basic skills required for would-be accident investigators to conduct meaningful and effective accident investigations are not addressed by HSG 245. It has reduced many accident investigations to checklists that result largely in the gathering of negative evidence,  unnecessary reviews and additional ‘systems related’ paper. This has lead many SME’s to shy away, surprised by the number of potential systems non-conformances and regulatory breaches that their accident investigations produced; despite having invested heavily in health and safety advice.


Terminology remains as perhaps the biggest single problem that untrained accident investigators and industry unwittingly face. Regarding, for instance, underlying and immediate cause, HSE Contract Research Report 344/2001 found that the majority of companies surveyed had failed to effectively discriminate, or understand, the distinction between them. HSG 245 compounds those failings.


Executive Comment

HSG 245 has encouraged SME’s and developing Organisations to look closely at their systems. It has also assisted the more mature Organisations to realise that many accidents occur despite the existence of adequate systems and controls. Both of these are positive results.


Historic models of causation may be questionable; however, the means by which truly unacceptable practices are exposed should, as taxpayers and accident preventionists, be immaterial to us. On the other hand, we must recognise and support those Organisations that do all that the law reasonably requires and assist them to remedy the oversights that make most legally compliant workplaces, accident prone.


Accident investigations often reveal numerous potential systems nonconformities; however, and whilst they must be addressed, they do not automatically equate, or relate, to cause.


Similarly, an accident investigation that identifies a breach that warrants an offence to be alleged will not, even if subsequently proved in court, have necessarily shown that the breach caused the associated accident. Whilst breaches must also be addressed, accident prevention requires that the cause of the accident be properly identified; otherwise, the resulting remedial intervention strategy will be pointless, if not counter productive. Unfortunately, many safety professionals and untrained accident investigators appear to halt their accident investigations upon finding an associated regulatory breach; this, in the belief that it presents both cause and remedy. According to the survey, many set out to do this; if so, HSG245 may be part of a pre-existing and more widespread process of circular counter productivity.  


The options may be simple; we can constantly and relentlessly identify systems and regulatory breaches via means that, reportedly, cannot fail to identify them; or, maintain appropriate levels of systems and regulatory compliance and seek out the causes of those accidents that continue to occur despite these.




To commence addressing things, many are sending senior officers and accident investigators for the higher level of training, awareness and competence that results from successfully attending and examining on an IIAI Approved Lead Accident Investigators’ Certificate course.


As a ‘first step’ to assessing your Organisation’s competencies and capabilities, why not contact the Institute to see how we might assist.

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