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                                              HSG245: ARCHIVE SUMMARY 2004-2005


Communications directed to the Institute of Industrial Accident Investigators regarding-


HSG245 “Investigating accidents and incidents-a workbook for employers, unions, safety representatives and safety professionals (HSE 2004).

In July 2004 the HSE released HSG245 ‘Investigating accidents and incidents-A workbook for employers, unions, safety representatives and safety professionals’.

186 communications were received on the matter of HSG245. The Examinations Panel considered and collated those communications up to and including the 1st February 2005 and provided the following qualified summary.


HSG245 'Investigating accidents and incidents...' will provide a useful basic resource for those who have no prior knowledge of the industrial accident investigation process and whose employers require industrial accident investigations to be conducted in this way. Whether or not industry will embrace the ‘model’ offered by HSG245 remains to be seen; historically, re-confirmed in CRR 344/2001, employers have not been prepared to record data in the way that HSG245 proposes.

62% of responses found some of the terminology in HSG245 to be unhelpful and 88% found the differentiation between Root Cause and Underlying Cause to be either awkward, unnecessary or unprecedented.


  • HSG245 ‘Investigating accidents and incidents...’ states that ‘Root causes are generally management, planning or organisational failings’; it also defines Underlying Cause as ‘the less obvious ‘system’ or ‘organisational’ reason’ for adverse events.
  • Contract Research Report 344/2001, ‘Accident investigation-The drivers methods and outcomes’, describes the need for employers to identify Immediate Cause and Underlying Cause. It makes no mention of any differentiation between Root Cause and Underlying Cause. CRR 344/2001 appears to use the term Underlying Cause to describe the managerial and organisational shortfalls that HSG245 [separately] labels as both Root Cause and Underlying Cause.
  • HSG65 ‘Successful health and safety management’ states that ‘Underlying causes are the management and organisational factors which explain why the event occurred’ and that these include...


  • The adequacy of health and safety policy.
  • How work is controlled, co-ordinated and supervised.
  • How the co-operation and involvement of employees is achieved.
  • The adequacy of the communication of health and safety information.
  • How competency is achieved and tested (including the provision of health and safety assistance).
  • The adequacy of planning, risk assessment and the design of RCSs.
  • The adequacy of measuring and monitoring activity.
  • The adequacy of review and audit arrangements. (p.63.).


  • In view of the distinctions made by HSG245 ‘Investigating accidents and incidents...’ a number of responses queried the identification of ‘Unsafe Acts’ as a category of Underlying Cause at p.4. of HSG245.
  • The grouping of RIDDOR Dangerous Occurrences with ‘near miss’ events was considered to be potentially misleading.
  • The use of the term ‘adverse event’ in HSG245 ‘Investigating accidents and incidents...’ drew a large number of responses. Equally large were the numbers that questioned the definitions offered on p.2. of HSG245. Many respondents considered; 1) that the information accompanying the labeled (‘near miss’ and ‘undesired circumstance’) scaffold diagrams was inadequate and potentially mis-leading; and 2) that the defining of ‘untrained nurses handling heavy patients’ as being an ‘undesired circumstance’ required explanation.
  • In addition, paragraph 3. of p.6. indicates that an ‘undesired circumstance’ can translate ‘into a near miss’. As such, it was felt that it (undesired circumstance) should have been placed into a category of its own. This may have allowed for clearer explanation and a measure of justification for its inclusion. As it stands, respondents that discussed the point in detail queried the whereabouts of ‘contributory cause’.
  • All of the respondents who discussed paragraph 2, p.6. of HSG245 felt that its comments were both erroneous and misleading. Most discussed section 3(1) of the Health and Safety at Work etc Act 1974 and cited R v Board of Trustees of the Science Museum [1993] 1 W.L.R 1171.

    The majority considered that the closing line of paragraph 7, p.6. could have been included in paragraph 2 along with the inclusion of the term ‘non-employees’ instead of, or as well as, ‘the public’.

In addition to responses or communications arising from the interim summary, responses were invited in order to generate discussion on...

  • The meaning or possible meaning of Root Cause and Underlying Cause within the field of Industrial Accident Investigation.
  • The potential effects of, and problems for, HSG245 due to the definitions it has used.
  • The potential utility of HSG245 in an adversarial setting.
  • With reference to the Causal Spectrum (IIAI 1997), whether Underlying Cause (and possibly root cause) has been ‘relocated’.


Communications were still being received regarding (in particular) the worked example on pages 21-34 of HSG245 prompting the Examinations Panel to utilise that ‘adverse event report’ as the subject of a secondary investigation.


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