Diploma Unit IA - Element IA2 - Loss causation and incident investigation July 2014

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1 NEBOSH International Diploma in Occupational Health and Safety Element IA2 Loss causation and incident investigation 1 4 Licence details Learning outcomes ACT Associates Limited Victoria House, Lower High Street, Stourbridge DY8 1TA ACT Associates Limited. Third Edition December 2013 All rights reserved. No part of this presentation may be stored in a retrieval system, reproduced, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise without either the prior written permission of the Publishers. This presentation may not be lent, resold, hired out or otherwise disposed of by way of trade in any form other than that in which it is published, without the prior consent of the Publishers. This presentation may not be reproduced in any form without prior consent of the Publishers other than a single copy thumbnail handout for immediate use by the tutor. Whilst every effort is made to ensure the completeness and accuracy of the information contained herein, RMS can bear no liability for any omission or error. Issued to: Single Licence Licence No: Explain the theories of loss causation Explain the quantitative analysis of accident/incident ill health, limitations of their application, and their presentation in numerical and graphical form Explain the external and the internal reporting and recording systems for loss events (injuries, ill health, dangerous occurrences) and near misses Explain loss and near miss investigations; the requirements, benefits, the procedures, the documentation, and the involvement of and communication with relevant staff and representatives 2 5 Unit IA International Management of Health and Safety 3 6 Sample of PowerPoint presentation for NEBOSH International Diploma in Occupational Health and Safety 1

2 Difference between a near miss and a fatal accident/incident in terms of time and distance can be very small The damage to persons or property is not the accident, but part of the effects of the accident/incident (i.e. the result or consequences) An old adage says never waste an accident Every accident/incident constitutes an opportunity to correct some problem A near miss which has the potential to cause loss is just as important as a serious injury/damage 7 10 Losses result from lack of control Revealed by loss causing events Definition of an accident is: An unplanned, uncontrolled event which led to, or could have led to injury to persons, damage to plant or some other loss to the company Definition includes near misses', i.e. where no injury or damage etc. occurs Important not to think of injuries, damage and other losses as accidents/incidents, but rather as the results of accidents/incidents Some years ago, a study of 1,750,000 accidents/incidents, in 21 industry sectors, led by Frank Bird, showed that there is a fixed ratio between accidents/incidents resulting in losses of different severity, including ones where no loss occurred, i.e. near misses) This can be demonstrated with an accident/incident ratio pyramid model 8 11 Accident/Incident/Near miss Accident ratio study Accident/Incident Near miss Source: Frank Bird. Source: UK, HSG Sample of PowerPoint presentation for NEBOSH International Diploma in Occupational Health and Safety 2

3 Accident ratio pyramid 13 Source: UK, HSG96 the costs of accidents at work. 16 Limitations Frank Bird s findings are not uniform throughout industry The accident/incident ratio studies may not necessarily show the extent of the loss to the organisation There are no universally agreed definitions of each subset of accident type Statistical analysis of loss events relies on large numbers, comparable work and worker skills over the measured timeframe, to be effective In smaller organisations, the first recorded accident/incident may be the top event, i.e. fatality or major injury Near miss reporting may mean different things to different people Accident ratio triangle HW Heinrich proposed one of the first coherent theories of accident/incident causation in the mid 1920s Suggested that accidents/incident were not acts of God but were caused by the failures of people His domino theory suggested that the series of events, which led to an injury or some other loss, were a succession of events which followed a logical pattern Source: OGP, International Association of Oil & Gas Producers Use If only those resulting in injury are considered, many opportunities to learn about what goes wrong are being missed If near misses are also studied they can provide more opportunities to learn and possibly prevent some of the events that result in injury The Frank Bird accident/incident pyramid model includes property damage in addition to near misses The accident/incident pyramid models help to convince people of the value of reporting a wide range of events and show that there are usually more near misses than injury events 18 Accident causation domino Source: H.W. Heinrich. Sample of PowerPoint presentation for NEBOSH International Diploma in Occupational Health and Safety 3

4 Further research by the International Loss Control Institute (ILCI) into accident causation led them to put forward a modified domino theory Lack of management control Policy Planning Organising Controlling Monitor Review Accident causation domino Sequence of dominoes Source: Frank Bird - ILCI. Source: UK, HSG Loss Event (accident/incident) Immediate (direct) causes Underlying (indirect or root) causes Organisational factors (Procedural) Job factors (Technical) Personal factors (Behavioural) Multiple accident causes Usually more than one causative factor Each of the multiple causation factors may be seen as one domino in its own line of dominoes (just as the roots of a tree branch out) Source: RMS Sample of PowerPoint presentation for NEBOSH International Diploma in Occupational Health and Safety 4

5 Latent and active failures Reason s model of accident causation Reason proposed four levels of human failure, each influencing the next The first level that Reason identifies is unsafe acts of persons, which ultimately lead to the accident/incident These unsafe acts were considered to relate to the errors, such as the skill based slips/lapses and mistakes identified in Rasmussen s work in 1987 called active failures Reason identified three further levels of human failure that comprised latent failures Latent and active failures Reason s model of accident causation The second level of human failure involves preconditions that lead to unsafe acts taking place In many instances, these preconditions can be traced back to instances of unsafe supervision, the third level of human failure identified by Reason Importantly, Reason s identified that causation did not stop at the supervisory level He recognised that the fourth level, the organisation itself, can impact on performance at all levels Quantitative analysis of accident/incident and ill health Analysis of accident/incident and ill health allows general trends to be shown This can also help to raise awareness in the minds of both managers and workers of health and safety in general and specific problems in particular Collection of allows costs to be calculated, which can increase the likelihood of resources being allocated J. Reason s accident/incident model Part only of the complete Element IA2 Loss causation and incident investigation Source: Reason/RMS Sample of PowerPoint presentation for NEBOSH International Diploma in Occupational Health and Safety 5