Introduction to Fire Safety Management

Introduction to Fire Safety Management
achieve a level of consistency some organisations apply
a simple matrix which provides an indication of whether
the investigation should be conducted at minimal, low,
medium or high level, see Table 12.2.
Involving others
Where an adverse event is likely to be investigated by a
third party it is best practice to attempt to coordinate the
investigation, this minimises disruption to the workplace
and employees and demonstrates a willingness by all
parties to be open and objective. However, it should be
borne in mind that none of the third parties are obliged
to take part in a joint investigation of the event, although
it is normal that each party will share some information
relating to their investigation.
For those investigations that are carried out entirely
in-house there is often predetermined levels of investigation.
It is important that a clear policy detailing the
employer’s arrangements for investigating safety events
exists to enable managers and other employees at all
levels to initiate the necessary investigation with the
least delay.
Establishing the cause
Regardless of the level of investigation, its purpose is to
establish:
➤ The immediate causes of the loss damage or potential
damage
➤ The underlying causes
➤ The root causes.
The immediate causes – the most obvious reason
or reasons why the adverse event happened, e.g. cloths
left on top of a hot plate.
The underlying causes – there will be a number
of unsafe acts and unsafe conditions that have come
together to result in the adverse event. For example, a
fi re has started in a piece of fi xed electrical equipment.
The underlying cause may be that clothing discarded
by an employee has covered the cooling vents on the
equipment. The underlying cause in this case is relatively
simple, the equipment overheated to the point of ignition
caused by blocked ventilation ports. Table 12.4 gives
further examples.
The root cause – the root causes of all accidents
are failures of management systems, for example:
➤ Lack of adequate fi re risk assessment of the
workplace
➤ Failure to provide appropriate work equipment
➤ Lack of provision of adequate storage for employees’
clothing
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Table 12.4 Examples of unsafe acts and unsafe conditions
that may lead to damage or injury
Unsafe acts Unsafe conditions
Unauthorised hot work Flammable atmosphere cause
by fl ammable liquid leaking
from inadequate container
Storing fl ammable liquid Not having suffi cient suitable
in an unsuitable container facilities to store fl ammable
liquids in the workplace
Walking across a slippery Slippery fl oor caused by
fl oor leaking oil heater
Using inappropriate Faulty ladder available in
equipment to gain workplace
access at height
Opening an electrical An unlocked electrical supply
supply panel panel
Operator’s ventilation No safety device on the
block, ventilation ports equipment which cuts off
of electrical appliance power in the event of
overheating
➤ Inadequate information to/training of employees in
the importance of keeping vents clear
➤ Failure to actively monitor the workplace to identify
blocked ventilation ports on electrical equipment
➤ Lack of suffi ciently competent staff.
In order to establish the immediate, underlying
and root causes of an adverse event
the HSE suggest a four step approach:
1. Gathering information
2. Analysing information
3. Identifying risk control measures
4. Agreeing and implementing an action
plan.
Gathering information
It is important in the beginning of an investigation to
gather the information immediately or soon after the
adverse event occurs or is discovered because:
➤ The location of the event will be in the same condition,
i.e. light levels, temperature, etc.
➤ People’s memories will be fresh
➤ There will be limited opportunity for a consensus
view to emerge from witnesses.