​Introduction

Where a serious incident occurs involving death, serious injury or substantial damage to property, or where circumstances otherwise warrant, for example a near miss with significant STFC learning, a Board of Enquiry will be convened as quickly as possible to investigate the circumstances.

Purpose of boards of inquiry

The purpose of a Board of Inquiry is to establish the facts, to ascertain the cause of the incident and, where practicable, to recommend safeguards to prevent a recurrence. The Board has no legal powers and it is not part of its duty to recommend disciplinary action or apportion blame.

Health and safety at work etc act 1974 provisions

Under the Health and Safety at Work etc. Act 1974 an Inspector of the Health and Safety Executive may, if he chooses, conduct his own investigation into the incident and have access to the proceedings of the Board of Inquiry. However the Health and Safety Executive has assured the Council that it is most unlikely that a prosecution would be approved against an individual where the only evidence against him was an admission which had been made to a Board of Inquiry.

Safety Representatives may, not withstanding the Board of Inquiry and Safety Inspector's investigations, exercise their rights of inspection and examination of any incident under the Regulations on Safety Representatives and Safety Committees 1977.

Composition

The membership of a Board of Inquiry will be at the discretion of the convening authority and will consist of a Chairman, a Secretary and such members as the convening authority thinks fit; they will all be persons who had no direct responsibility for the operations during the course of which the incident occurred. The Chairman shall be a STFC Director independent of the incident. No member of the local SHE Group shall be a member of the Board. The Board will include one member nominated by the Staff Side and/or one by the Trade Union Side.

Terms of reference

The Board's terms of-reference will be prescribed by the convening authority but will normally take the following form:

"In accordance with the provisions of STFC SHE Code 5 to enquire into the circumstances of..... which occurred on....... at....... to make recommendations and to report to (the convening authority) as soon as possible".

A notice will be published setting out the terms of reference and composition of the Board and inviting witnesses who wish to give evidence to notify the Board's Secretary.

No employee of the Council can be compelled to give evidence, whether written or oral, to a Board of Inquiry. However, staff are reminded that in accordance with Section 7 (b) of the Health and Safety at work etc Act 1974 it is the duty of every employee while at work, to cooperate with their employer on safety matters.

Method of inquiry

The Board will meet as soon as possible after the occurrence of the incident and thereafter, whenever and wherever necessary (including as appropriate, a visit to the site) to collect all the relevant facts, to ascertain the cause of the incident and to make recommendations to prevent a recurrence. The inquiry will be conducted by formal questioning of each witness or expert (normally individually and not in the presence of other witnesses or experts) and by examining such plant, papers, drawings, etc. as are deemed necessary.

Format of report of a board of enquiry

• 1. Introduction (terms of reference, membership etc) - Annex 1
  • 1.1 If required, Executive Summary.
    
    
• 2. Conduct of the Enquiry (brief description of how the Enquiry was carried out) - Annex 2
  
  
• 3. Details of the Accident/Incident
  • 3.1 The Accident/Incident (description of what happened and when) - Annex 3.
  • 3.2 Time line for the incident and the immediate response.
  • 3.3 Nature of the work in progress and circumstances in which the incident occurred.
  • 3.4 Could the accident/incident have been more serious (ie was it also a narrow escape from something worse).
    
    
• 4. Examination of the Evidence
  • 4.1 Risk assessments, task instructions/method statements - did they exist? were they adequate? did they envisage the accident/incident which has happened? did the task instructions incorporate the findings of the risk assessment?
  • 4.2 Equipment - was the correct equipment being used?  was it being used correctly?; was it fit for purpose? did the equipment fail? was the equipment properly maintained (do records exist)?
  • 4.3 Operator actions - were the task instructions/method statement being followed? if the operators deviated from the instructions, why?
  • 4.4 Training - were the operators trained?  are there records? was the training adequate?
    
    
• 5. Findings
  • 5.1The Board's conclusions as to why the accident/incident happened.
  • 5.2 The Board's conclusions about whether a similar accident/incident could happen elsewhere in STFC.
    
    
• 6. Recommendations and Observations
  • 6.1 The Board's specific recommendations to avoid a repeat of the accident/incident.
  • 6.2 More general recommendations and observations.
    
    
• 7. Annex 1 - commissioning letter/memo.
• 8. Annex 2 - list of people interviewed/other sources of information and evidence.
• 9. Annex 3 - photographs, statements etc.

Sunmissions and distribution of report

The report will be submitted by the Chairman of the Board to the STFC Chief Executive, Directors with responsibility for Safety at STFC laboratories and the Head of SHE.

No member of the Board may divulge the proceedings or findings of the Board except with the express approval of those to whom the report has been submitted.

Following its consideration by STFC Chief Executive, Directors with responsibility for Safety at STFC laboratories and the Head of SHE its further distribution will be determined. However, since, the main purpose of holding a Board of Enquiry is to analyse the adequacy of the Council's policy and practice in relation to the particular circumstances, copies of the report should be distributed to appropriate senior staff and to the designated Safety Officer(s) at each of the Council's Establishments.