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Element A2
Element A2
LOSS CAUSATION
ACCIDENT =
Unplanned, uncontrolled event (NOT the result)
HSE –
Accident = an event that results in injury or ill health
Incident = Near Miss, undesired circumstance.
Near Miss = has potential to cause harm (incl D.O’s)
Undesired Circumstance = Set of conditions / circ’s that
have potential to cause injury or ill health.
HSG245 = Adverse Events Accidents
Incidents
Element A2
LOSS CAUSATION
ACCIDENT RATIO STUDIES
Frank Bird – showed fixed ratio between losses of
differing severity (+ near misses)
Element A2
LOSS CAUSATION
ACCIDENT RATIO STUDIES
HSE – (HSG96)
1 over 3 day
56+ Minor (first aid only)
3570+ Non injury acc
Uses
Learn from minor / n.misses to help prevent major
Helps convince – reporting – more opp’s to learn
Limitations
Not uniform throughout industry
Cultural and reporting differences
Element A2
LOSS CAUSATION
DOMINO THEORY
HEINRICH
Series of events
Succession of events, follows logical pattern
FRANK BIRD
Modified theory
Element A2
LOSS CAUSATION
DOMINO THEORY
FRANK BIRD
Modified theory:-
Loss –
Consequence of acc
People, prop, process, or potential loss of profit
Event
Acc or Inc
Element A2
LOSS CAUSATION
DOMINO THEORY
FRANK BIRD
Modified theory:-
Immediate (direct) causes
Workplace hazards
Unsafe acts / conditions (symptoms)
Underlying (indirect) causes
Org / Proc / Job factors / Tech
Personal / Behaviour
Element A2
LOSS CAUSATION
DOMINO THEORY
FRANK BIRD
Modified theory:-
Underlying (cont..)
Usually lack of MGT Control
Element A2
LOSS CAUSATION
DOMINO THEORY
FRANK BIRD
Modified theory:-
Dealing with imm. Cause
Will only prevent this sequence
Dealing with all causes (esp ROOT)
Can prevent whole series of adverse events
AN IMPORTANT ASPECT IN LOSS CAUSATION /
PREVENTION
Thorough investigation to determine
root causes is necessary
Element A2
LOSS CAUSATION
DOMINO THEORY
FRANK BIRD
Modified theory:-
Immediate cause
Less obvious “system” or “organisational” reason
E.g. checks are not carried out by supervisors
Root causes
Initiating event or failing
Generally MGT / Planning / Org failings
Element A2
LOSS CAUSATION
DOMINO THEORY
FRANK BIRD
Modified theory:-
Multiple accident causes
Usually more than one causative factor in accident
DOMINO
Element A2
LOSS CAUSATION
LATENT AND ACTIVE FAILURES
Latent = hidden
Accident
Train crash
Unsafe Acts (active failure)
Driver error
Pre Conditons (latent)
Tired, poor comm, faulty signal
Unsafe Supervison (latent)
Asked to work o/t
Organisational influences (latent)
Limited resources @ line MGT level
Element A2
ANALYISIS OF DATA
AFR
Accidents compared with time
No of acc / total hrs worked x 1,000,000
Can be 100,000 or less to bring no’s to manageable size
AIR (accident incident rate)
Accidents compared with no of people
No of acc / Avg no employed x 10,000
Element A2
ANALYISIS OF DATA
Accident Severity Rate
Avg no of days lost compared with hours worked
No of lost days / man hrs worked total x 1,000
Ill Health Prevalence rate
Similar to AIR but ill health not acc’s
No of ill health conditions / no of people exposed to
agent x 1000
Workplace or population
Element A2
ANALYISIS OF DATA
Fatality
Won’t show up on severity rate – no lost time
Use all rates together
And compare using same definitions (100,000 etc)
Rise in rates
Not necessarily no improvement
Could be reporting rates are better therefore improved
culture
Must be carefully analysed
Easier to see trends in graphical or numerical format
Element A2
REPORTING AND RECORDING
Stat req’s
RIDDOR 1995
Reports sent to relevant authority to compile stats and
show trends
To highlight problem areas in particular industries or
companies
Form F2508 within 10 days
Plus telephone if death or major injury (incl suicide)
Schedule 1 – Major injuries
Schedule 2 – D. Occ’s
Schedule 3 – Diseases
Element A2
REPORTING AND RECORDING
Stat req’s
Accident Book (B1510)
Must be kept at location
Must be easily accessible at all reasonable times
Employer must then investigate
Records kept for 3 years
Element A2
INTERNAL REPORTING / RECORDING
SYSTEMS
Relevant report forms
Accident book
First aid / med treatment book
Docs Reports
Sickness absence reports
Acc / Near miss reprots
RIDDOR reports (F2508)
Element A2
INTERNAL REPORTING / RECORDING
SYSTEMS
Investigation reports
Level 1 – Line MGR
Level 2 – Other MGR / H+S Pract
Level 3 – Investigation team
What , How, Why, Recommendations…
Element A2
INTERNAL REPORTING / RECORDING
SYSTEMS
Following fatality
Inform
Enforcing authority
SNR MGR
H+S Prac
Coroner
Next of kin
Reps
Other employees
Insurance company
Element A2
INTERNAL REPORTING / RECORDING
SYSTEMS
Following fatality
Inform
Enforcing authority
SNR MGR
H+S Prac
Coroner
Next of kin
Reps
Other employees
Insurance company
Element A2
LOSS INVESTIGATIONS
Not overtly stated in law…
…that accidents must be investigated
Implied – HASAW
Prevent reoccurrence
Investigate
Measures is place
HSG65
Ensures compliance on investigation requirements
Element A2
LOSS INVESTIGATIONS
HSG 245
Step 1
Gather Info – where, when, who, interviews, photos etc
Step 2
Analyse info – what and why, consider human error (HSG48)
Step 3
Identify suitable risk control measures – solutions
Tech / eng more reliable than behaviour
Element A2
LOSS INVESTIGATIONS
HSG 245
Step 4
Action Plan / Implementation – short term / long term
SMART
Specific
Measurable
Achievable
Realistic
Timescales
Element A2
LOSS INVESTIGATIONS
PURPOSE OF INVESTIGATIONS
Discover underlying causes
Prevent re-occurrence
Establish legal liability
Data gathering
Identification of trends or patterns
NOT TO BLAME!!
Element A2
LOSS INVESTIGATIONS
PURPOSE OF INVESTIGATIONS
If Human Error
Causes must be investigated
If lack of training or unsuitability for job -
MGT failings
If wilful / intentional acts
Human error
Element A2
LOSS INVESTIGATIONS
WRITTEN REPORTS
Exec summary
Main body
Conclusions and recommendations
Remedial actions
Lessons learnt
Share best practice
Element A2
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