Professional Documents
Culture Documents
Causation Theories
Fault of Person
Accident
Injury
Bird & Loftus extended Heinrichs theory to encompass the influence of management in the cause & effect of accidents They suggested a modified sequence as follows:
Lack of management control, permitting Basic causes (personal & job factors), leading to Immediate causes (substandard practices or conditions), which are the direct cause of The accident, which results in Loss (negligible, minor, serious or catastrophic
This modified sequence can be applied to every accident and is of basic importance to loss control management
Multiple Causation
May be more than one cause, not only in sequence, but occurring at the same time q In accident investigation all causes must be identified q Usually simple accidents have a single cause q Major disasters normally have multiple causes
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Multiple Causation
Cause a Cause b Cause c Accident Cause d Cause e Cause f Unsafe Condition Injury or Damage Unsafe Act
Unsafe Acts
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Categories:
Operating without clearance Operating at unsafe speed Rendering safety devices inoperative Using unsafe equipment, or using it unsafely Unsafe methods e.g. loading, carrying, mixing Adopting unsafe position or posture Working on moving or dangerous equipment Horseplay e.g. distracting, teasing, startling Failure to wear PPE Lack of concentration; fatigue or ill health Human Factors
Unsafe Acts
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Unsafe Conditions
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Categories:
Inadequate guarding Unguarded machinery Defective, rough, sharp, slippery, decayed, cracked surfaces Unsafely designed equipment Poor housekeeping, congestion Inadequate lighting, glare, reflections Inadequate ventilation, contaminated air Unsafe clothing or PPE Unsafe processes Hot, humid or noisy environment
Unsafe Acts/Conditions
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The picture shows how unsafe acts & conditions may interact to produce an accident. Accident potential is increased when unsafe acts & conditions occur simultaneously. Of course, this is not to say that an act or condition alone could not result in an accident.
Unsafe Acts
Accident Potential
Unsafe Conditions
Accident Reporting
Information should be kept for all injuries, and preferably for near misses q The safety practitioner needs to design a suitable form to ensure that he gets the information that he needs for investigations
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Format:
Name & personal details of victim Date, day and time of accident Location of accident Occupation of victim Job being done at time Nature of injury or damage What inflicted the injury or damage Who had control of the cause of the injury or damage What actually happened Basic and immediate causes Immediate remedial action taken Recommendations to prevent recurrence
Accident records are useless if they are used only to count accidents. Detailed and thorough study of the records as part of the normal ongoing accident prevention programme should yield the following useful information:
Relative importance of the various injury & damage sources Conditions, processes, machines and activities which cause the injuries/damage The extent of repetition of each type of injury or accident in each operation Accident repeaters, I.e. those workers who tend to be repeatedly injured or are involved in more accidents How to prevent similar accidents in future
Accident Investigation
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A joint investigation by company/safety rep is often a good idea An investigation which does not discover what went wrong, and produce some useful information and recommendations for corrective action, is just a waste of time
Accident Investigation
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Initial Actions
Questioning the victim
Treatment of victim is first priority Immediate questioning may not be possible - they should be allowed to collect their thoughts and control their nerves Investigator can usually go to accident scene and get a fairly complete story from on-site conditions and witnesses In all serious accidents and in all other cases where practicable, conditions at accident scene should remain undisturbed until investigation is complete
Investigators
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Immediate supervisor:
Likely to know most about the situation Knows his own people better than anyone Has personal interest in determining causes, as accidents affect the efficiency and morale of his department Familiarity with staff could cause problems
Investigators
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Recognising Hazards
Familiarity with plant, equipment and layout of operations will assist in recognising hazards that have been overlooked for some time Unsafe acts, as well as conditions, contribute towards most accidents It is not sufficient merely to recommend fitting a guard while overlooking the unsafe act, such as rendering the guard ineffective or placing hands in the danger zone It is also insufficient to limit attention to an unsafe act if fitting a better guard would reduce the likelihood of injury
Investigators
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Safety Practitioner
Necessary in more serious cases Supervisor may not have necessary authority Should seek assistance from local supervisor Investigator must have authority to go as far as is necessary to get to the cause of the problem
The Investigation
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Promptness
As soon as possible after the event Facts will be easier to determine and more details will be remembered by those involved
Fire
Helpful if investigator is present during the fire Investigator may gain useful information by watching the activities of firemen
The Investigation
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Evidence
Depending on severity of any injuries or damage, investigator should be present during clear-up and reinstatement as valuable clues may otherwise be missed Failing which, supervisor should take it upon himself to collect the necessary evidence
The Investigation
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Equipment
Photographic equipment Portable lights (electricity may be switched off or accident scene may be poorly lit) Sketchpad, pencils and measuring equipment Record-keeping equipment e.g. notebook and cassette recorder Sample collection equipment e.g. jars, paper bags, cartons etc. Tools for cleaning debris or spillages should also be available Portable gas/vapour detecting equipment
Careful, detailed look at accident scene, evaluating and noting the following: Extent & severity of damage Damage to surrounding property Environmental conditions which may have had some bearing on the accident, such as temperature, ventilation, humidity and illumination Survey the accident scene to see if there are any obvious dangerous physical conditions which may have been responsible for the accident
In the case of spillages, splashes or other escapes of poisonous, explosive, flammable or other dangerous material, it may be necessary to take samples for subsequent investigation Where machinery or other equipment has been involved, it may be necessary to issue instructions prohibiting the use or repair of it until the investigation has been completed
Easy to upset people when asking questions about what has been done, or what has not been done Casual remarks made during the site inspection may be quite revealing and the investigator should continue to talk to any personnel involved near the scene of the accident This would also serve as an ideal opportunity to explain the object of the exercise is to discover and root out the causes so as to prevent a repetition. It is not to apportion blame or to criticise any individual
Interviewing Witnesses
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Types of Witness
Primary witness
The victim
Secondary witness
Extremely rare, the eyewitness How many people really see the instant of an accident?
Tertiary witness
Can offer variety of corroborative statements regarding the acts of people or environmental
Interviewing Witnesses
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Interviewing Witnesses
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Interview Location
Best to carry out interviews at scene of accident, as it is easier for those involved to communicate effectively with props close to hand Easier to explain what happened if witnesses are able to point out specific things and recall their actions related to specific locations
Interviewing Witnesses
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Question Phrasing
Open ended question - what, where, when, how or who Questions starting with why may put witness on the defensive Typical questions:
What happened? What did you see?What time was it? Where were you at the time? Where was the victim? When did you realise something was wrong? How did it happen? How were you involved? How could it have been prevented? Who else was involved? Who else saw it? Who reported it?
Interviewing Witnesses
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Attitude
What happened will often promote the fullest response and it is vital the investigator listens, without interruption, to the witnesss account of the accident If something is not understood, investigator should wait until witness has completed his account before asking for clarification Do not disagree with any of witnesss statement or make any judgements on his evidence alone What a witness believes to have happened will depend to some extent on just how he perceived the situation, even though this might conflict with the actual facts
Interviewing Witnesses
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Conclusion
When witnesss account of accident has been heard, investigator should repeat it to witness to ensure account is fully understood Interview should be concluded on a positive note, which is best achieved by discussing any ideas he may have regarding prevention of a similar occurrence - this will serve to reaffirm the purpose of the interview and ensure the witnesss further co-operation, should it be needed
ALL incidents/accidents should be investigated Purpose is to find the cause, with the intention of preventing a recurrence, rather than apportioning blame An injury usually involves some degree of blame falling on management, supervision, victim or workers