Element IA2: Loss Causation and incident investigation

1.Outline the five factors in Heinrichs accident sequence.

injury, caused by an ...

accident, due to an .....
unsafe act and/or mechanical or physical hazard, due to the ....
fault of the person, caused by their ....
ancestry and Social Environment.

2.How does Bird and Loftus theory of accident causation differ from Heinrichs?

Bird and Loftus update introduced two new concepts;

the influence of management and managerial error;
loss, as the result of an accident could be production losses, property damage or
wastage of other assets, as well as injuries.

3. What important principle of accident causation theory does accident ratio studies
illustrate?

Accident Ratio studies. Frank Bird showed that there is a fixed ratio between losses of
different severity demonstrated with a pyramid model. Several versions of this pyramid
including: HSG96 The Costs of Accidents at Work.
Limitations
Birds findings are not uniform throughout industry and differ due possibly to cultural
differences, the level of risk and level of reporting.
May not show the extent of loss to the organisation.
No universally agreed definition of each subset accident type.

4. What useful information and benefits can internal accident reporting and recording
systems provide?

Internal accident reporting and recording systems can provide information on

damage, injury and ill-health. The information gathered from accident investigation,
health surveillance and absence records can also be useful when risk evaluation is
required. Near miss information can show where the potential for harm is.
Internal accident reporting and recording systems can provide information relevant to
the issues being considered and sources will also be easy to access and should
clarification be required, questions can be posed to the relevant people.

5. What are the purposes of accident and ill-health investigation?

to fulfil the legal requirement;

to determine the cost of an accident;
to determine compliance with applicable safety regulations;
to process workers' compensation claims;

6. Define what is meant by the term accident.

An accident is an unexpected (or unplanned/unwanted) workplace event that causes injury

or illness to an employee.
7. With reference to H W Heinrich and Bird and Loftus theories:

a. Define the term accident causation.

b. Outline the two new concepts introduced by Bird and Loftus.
a. Accident causation the occurrence of an injury invariably results from a complicated
sequence of factors, the last one of which being the accident itself.
b. Two new concepts introduced by Bird and Loftus include:
the influence of management and managerial error;
loss, as the result of an accident could be production losses, property damage or
wastage of other assets, as well as injuries

8. With reference to Accident Causation and Human Error:

Define the following terms: immediate, indirect

a. Identify three types of unsafe acts and unsafe conditions and provide
examples of each.
b. Outline three underlying causes of accidents.

Immediate
Immediate or direct causes of accidents can be due to unsafe acts and unsafe
conditions which can be considered as workplace hazards e.g. unsafe conditions
such as trailing cables in the office environment which gives rise to an accident.

Indirect
Indirect causes are the underlying root causes of accidents and are not always easy
to identify. These will explain why the act happened or condition arose and fall into
three major categories, organisational (procedural) factors, job (technical) factors and
Personal (behavioural) factors.

Unsafe Acts
failure to use personal protective equipment,
leaving equipment in a dangerous condition,
working without authority (e.g. no permit to work),
horseplay,
using equipment in the wrong way,
failure to warn others of danger.

Unsafe Conditions
poor housekeeping,
exposure to radiation,
poor lighting or ventilation,
badly-maintained equipment.
Underlying causes
lack of policies and procedures,
lack of training/supervision,
lack of resources,
unsuitability of a person for particular task.
9. a. Define active and latent failures.
b. Choose three examples of latent failure and outline how these failures can
lead to accidents in the workplace.
c. Outline the two reasons why latent failures are so important to accident
investigation.

a. Active Failure
Active Failures have an immediate consequence and are usually made by front-
line people such as drivers, control room and machine operators. These
immediately proceed, and are the direct cause, of the accident.

Latent failure
Latent Failures are those aspects of the organisation which can immediately
predispose active failures.

b. Examples of latent failure (choose three):

poor design of plant and equipment;
ineffective training;
inadequate supervision;
ineffective communications; and
uncertainties in roles and responsibilities
c. Latent failures are crucially important to accident prevention for two reasons:
1. If they are not resolved, the probability of repeat (or similar) accidents remains high
regardless of what other action is taken;
2. As one latent failure often influences several potential errors, removing latent
failures can be a very cost-effective route to accident prevention

10. With reference to Reasons Classification of Active Failure:

a. Define intentional and unintentional error.

b. Define the term violation as it applies to health and safety
c. Define routine, situational and exceptional violations and provide an
example of each.
d. Outline the differences between rule based and knowledge based
mistakes.

a. Intentional error
Intentional errors are described as violations.

Unintentional Error
Unintentional errors are classified as either slips/lapses or mistakes.

b. Violation
Violations are any deliberate deviation from the rules, procedures, instructions and
regulations, which are deemed necessary for the safe or efficient operation and
maintenance of plant or equipment. Breaches in these rules could be
accidental/unintentional or deliberate.

a. Routine violation
Routine Violations are ones where breaking the rule or procedure has become the
normal way of working. The violating behaviour is normally automatic and
unconscious but the violation is recognised as such by the individual(s) if questioned.
 This can be due to cutting corners, saving time, or a belief that the rules are no
longer applicable.

Situational Violation
Situational Violations occur because of limitations in the employee's immediate work
space or environment. These include the design and condition of the work area, time
pressure, number of staff, supervision, equipment availability and design and factors
outside the organisation's control, such as weather and time of day. These violations
often occur when a rule is impossible or extremely difficult to apply in a particular
situation

Exceptional Violation
Exceptional Violations are violations that are rare and happen only in particular
circumstances, often when something goes wrong. They occur to a large extent at
the knowledge-based level. The individual, in attempting to solve a novel problem,
violates a rule to achieve the desired goal.

d. Rule based mistakes these mistakes can occur when we believe that we are
doing the wrong thing believing it to be right. E.g. following rules and procedures
when they simply dont apply.

Knowledge based mistakes these mistakes can occur when we have to apply
knowledge based reasoning. When a situation is miscalculated or misdiagnosed then
mistakes can occur.

11. a. Define the term latent failure

b. Outline two advantages and two disadvantages of safety rules in the
workplace.
c. Outline two ways in which training can have a negative effect on health and
safety.

a. Latent failures are the factors or circumstances within an organisation which

increase the likelihood of active failures.

Advantages: Rules and procedures provide the framework upon which safety
assurance is built claimed to be effective control measures.

Disadvantages: Studies have shown that safety rules and procedures are often:
written negatively, concentrating on should not be done rather than on what
should be done;
impractical;
in conflict with other rules

Training can have a negative effect on health and safety when:

Hazard awareness is often assumed rather than training
Training should concentrate on what is safe rather than unsafe, what to do
rather than what not to do.
Training is not always consistent with the rules and procedures
12. a. Define the terms slips and lapses
b. Outline three slips and three lapses and how these can be eliminated by
design improvements.
c. Outline three ways in which a persons motivation to violate health and
safe rules and procedures can be reduced.

A&b. Slips & lapses. These occur in routine tasks with operators who know the
process well and are experienced in their work:

They are action errors which occur whilst the task is being carried out;
They often involved missing a step out of a sequence or getting steps in
the wrong order and frequently arise from a lapse in attention;
Operating the wrong control through a lapse in attention or accidentally
selecting the wrong gear are typical examples.

Design improvements can eliminate slips and lapses by designing the

controls so that buttons cannot be pressed accidentally or out of their correct
operating sequence. Also, by ensuring that controls are more easily
identifiable and unique from others on the panel.

c. Suitable training from a qualified person.

Staff selection
Providing the correct tools and equipment for the task
Realistic time constraints to fulfil an order
Ensuring adequate supervision from qualified staff

13. With reference to Accident Investigation:

a. Identify in what areas an accident investigator requires competence and

provide two workplace examples to demonstrate your understanding.
b. Give reasons why the investigator should have a sound understanding of
the health and safety culture of the organisation.

a. an investigation would be conducted by someone expert in accident causation,

experienced in investigative techniques, fully knowledgeable of the work processes,
procedures, persons, and industrial relations environment of a particular situation.
The immediate supervisor is one such person.

b. It is important for an investigator to have a sound understanding of the

health and safety culture of the organisation. The health and safety procedures may
be circumvented in times of stress or crisis or simply forgotten when production or
other performance targets are threatened. Structural re-organisation or changes in
market conditions will produce feelings of uncertainty among the workforce which will
affect the health and safety culture. Poor levels of supervision and health and safety
information and training are significant factors in reducing safety awareness and
therefore the culture. The degree of consultation and involvement within the
workforce is crucial when it comes to health and safety matters. Human factors play a
huge part and affect the health and safety culture. Therefore it is important that
whoever is involved in the investigation has knowledge of all these factors so that
they can be taken into account during the conduct of the investigation itself.
14. Identify three reasons why accident investigations should be carried out.

Legal reasons why accidents should be investigated include:

To ensure the organisation is operating within the law
The Management of Health and Safety at Work Regulations 1999 Regulation 5
requires employers to plan, organise, control, monitor and review their health and
safety arrangements. Health and safety investigations form an essential part of this
process.
Following the Woolf Report on civil action, organisations are expected to make full
disclosure of the circumstances of an accident to the injured parties considering legal
action.

Also:
Investigation findings will provide essential information to insurers in the event of a
claim.
Information and insights can be gained from an investigation. Understanding what
went wrong and how.
Investigations provide an understanding of the ways people can be exposed to
substances or conditions that may affect their health.
Investigations provide a true snapshot of what really happens and how work is really
done.
Investigations can help to identify deficiencies in the risk control management
system.
Investigation provides information on how similar adverse events can be prevented.
Also, investigations can improve employee morale and attitudes towards health and
safety.
Management commitment to health and safety is visible when an incident is
investigated.
Investigations can improve upon managerial skills which can be applied to other
areas of the organisation.

15. a. Outline the necessary competencies for an accident investigation

team.
b. Explain the advantages and disadvantages of having the immediate
supervisor as part of the accident investigation team.
c. Define the terms unsafe acts and unsafe conditions with relation to
accident investigation.

a. . Members of the team should be familiar with health and safety good practice,
standards and legal requirements. The investigation team must include people who have
the necessary investigative skills (eg information gathering, interviewing, evaluating and
analysing).

b. The advantage is that this person is likely to know most about the work and persons
involved and the current conditions. Furthermore, the supervisor can usually take
immediate remedial action.
The counter-argument is that there may be an attempt to gloss over the supervisor's
shortcomings in the accident. This situation should not arise if the worker
representative(s) and the management members review all accident investigation reports
critically.

Unsafe acts and unsafe conditions with relation to accident investigation.

c. Unsafe acts and unsafe conditions usually need to coincide to result in an accident. An
individual may act in an unsafe manner for a long time without an accident happening
 (the frequent comment following an accident is that it's never happened before).
Similarly, there could be an accident waiting to happen (unsafe condition), but good
working practices have prevented it.
Unsafe acts
Operating without clearance
Operating or working 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 safe clothing or personal protective devices
Lack of concentration; fatigue or ill health

Unsafe conditions
Inadequate guarding: guards of inadequate height, strength, mesh etc;
Unguarded machinery, or the absence of the required guards
Defective, rough, sharp, slippery, decayed, cracked surfaces
Unsafely designed machines, tools
Unsafe arrangement, poor housekeeping, congestion, blocked exits.
Inadequate lighting, glare, reflections
Inadequate ventilation, contaminated air
Unsafe clothing; no goggles, gloves or mask
Unsafe processes; mechanical, chemical, electrical, nuclear;
Hot, humid or noisy environment

16. Identify three examples of the types of questions that an accident

investigator could ask with reference to task, materials and environmental
issues that could have caused an accident.

Task
Was a safe work procedure used?
Had conditions changed to make the normal procedure unsafe?
Were the appropriate tools and materials available?
Were they used?
Were safety devices working properly?
Was lockout used when necessary?

Materials
Was there an equipment failure?
What caused it to fail?
Was the machinery poorly designed?
Were hazardous substances involved?
Were they clearly identified?
Was a less hazardous alternative substance possible and available?
Was the raw material substandard in some way?
Should personal protective equipment (PPE) have been used?
Was the PPE used?

Environment
What were the weather conditions?
Was poor housekeeping a problem?
 Was it too hot or too cold?
Was noise a problem?
Was there adequate light?
Were toxic or hazardous gases, dusts, or fumes present?

17. Identify the type of evidence that should be recorded first and provide three
examples of this type.

Physical evidence including:

1. positions of injured workers
2. equipment being used
3. materials being used
4. safety devices in use
5. position of appropriate guards
6. position of controls of machinery
7. damage to equipment
8. housekeeping of area
9. weather conditions
10. lighting levels
11. noise levels

b. photographs of the accident scene are taken then should written notesbe
provided to accompany these photographs?

Yes. Even if photographs are taken, written notes about the location of these items at
the accident scene should be prepared.

18. With reference to Eye Witness Accounts:

a. Identify the advantages and disadvantages of interviewing a witness at the
scene of any accident

Advantages: You may decide to interview a witness at the scene of the accident,
where it is easier to establish the positions of each person involved and to obtain a
description of the events.

Disadvantages: it may be preferable to carry out interviews in the quiet of an office

where there will be fewer distractions. The decision may depend in part on the nature
of the accident and the mental state of the witnesses.

b. Why is it important to ask open questions during the interview process?

An open-ended question is one that cannot be answered by simply yes or no

(Closed questions). Closed questions that do require a yes or no answer can be
leading questions. During the interview process it is important that the interviewee
can give a full account of what happened in his own words. This will also ensure that
no crucial information is missed and new lines of questioning can be pursued as new
information is offered.
19. With regard to system design and implementation examples of root causes:
Outline three examples of system and three examples of implementation
weaknesses.

System weaknesses include:

Missing or inadequate safety policies/rules
Training programme not in place
Poorly written plans
Inadequate process
No procedures in place

Implementation weaknesses include:

Safety policies/rules are not being enforced
Safety training is not being conducted
Adequate safety supervision is not conducted
Incident/accident analysis is inconsistent
Lockout/tag out procedures are not reviewed annually

20. A publicity campaign -

(a) Outline reasons why the rate of reported accidents may have been a poor measure
of the campaigns effectiveness. (E2-Jan08-Q6-2)

Under Reported Earlier - they may have previously been under reported, perhaps
because some employees were unaware of the requirement to report and that raised
awareness, prompted by the advertising campaign, could have led to previously
unreported accidents now being reported.
In the absence of any other data, it would be almost impossible to tell whether or not
the increase was real.
Using the number of reported accidents is an unsatisfactory way of measuring the
effectiveness of the campaign since the anticipated improvement in H&S standards may
not be apparent until sometime after the campaign has ended.

(b) FOUR proactive monitoring techniques (E2-Jan08-Q6-8)

Physical inspections of the workplace - to identify hazards and unsafe conditions;

Safety Audits - where the systematic critical examination of all aspects of an
organisations health and safety performance against stated objectives is carried out;
Safety Tours - involving unscheduled inspections to observe the workplace in operation
without prior warning and to check on issues such as housekeeping, use of personal
protective equipment, gangways and the maintenance of fire exits;
Safety Sampling of a specific area or particular items of plant with repeat sampling to
observe trends; safety surveys involving in depth examinations of specific issues or
procedures such as changes in working practices;
Environmental monitoring and/or health surveillance;
Safety Climate measures such as the use of employee questionnaires;
Behavioral observation and measuring health and safety performance against set
targets.

21. Why accident should be investigated? (E2-Jul 2011 Q7- 4)

Identify the cause, both immediate and underlying
Prevent reoccurrence
Assess compliance with legal requirements
Demonstrate management commitment
 Restore employee morale
Obtain evidence and information
To use in subsequent civil claim/criminal prosecution
Ascertain cost of accident
Trend analysis
Identify need to review risk assessment
Review safe system of work

22. Steps to follow in-order to investigate the accident (E2-Jul 2011 Q7-10)
Information gathering
o Photographs, making sketches, measurements
Obtaining CCTV footage
Examining forklift/equipment condition
Determining speed of forklift at the time of accident
Determining load or what is carried
Safe load
Visibility when load was carried
Inspecting maintenance record & defect reports
Reasons for oil spillage, if any
Implementation of spillage procedure
Reasons for not following the procedure
Competency of driver/ equipment operator
Examining work place environment
o Floor condition
o Noise
o Illumination
Identifying person to be interviewed
o Injured person
o Witness
o Supervisor
Information analysis to ascertain immediate and underlying causes
Decision made to control similar risks
Actions to be taken with priority & responsibility
Periodic reviews to follow completion of work /progress
23. Underlying causes of accident (E2-Jul 2011 Q7-6)
Non availability / inadequate risk assessment
Cultural & organisational factors
Work pressure
Poor visitor control in the premises
Inadequate or poor signage (pedestrian walkways, roads)
Poor maintenance
Inadequate detection reporting procedure
Inadequate supervision or training
Poor safety culture
Lack of senior management commitment

24. Below is an extract from a record of an accident and investigation report (E2-Jul
2009-Q8-20)
a) Evaluate the record in terms of its suitability to provide adequate information for
record keeping purpose and for subsequent statistical analysis (E2-Jul 2009-Q8-10)

Incomplete
At time vague & other times of the accident
 Type of first aid was given
Precise action taken to prevent recurrence
Unclear in description of injury & treatment at hospital
Immediate & underline cause of the accident
Inconsistencies in a failure to provide info, finding
Identification of the injuries persons with different first names
Absences of witness

b) Keys stages in health and safety incident investigation (E2-Jul 2009-Q8-10)

Information gathering
o Location and time of the accident
o Affected persons
o Visual inspection of the seen
o Identify & Interviewing the witness
Analyze the information
o Reviewing relevant documents
o Analyse it, with FTA, ETA
o Establish immediate and underlying cause
Identify suitable control measures
o To prevent the reoccurrence.
Develop action plan & Implement
o Setting out objective to be achieved
o Identify the responsibility
Maintain the record.

Accident Statistics (Formulas)

Fatal
Accident Incident Rate = Number of fatalities 1,000
Number of employees
Accident
Incident Rate (AIR)

AIR = Number of notifiable accidents 1,000

Number of employees
Accident Frequency Rate (AFR)

AFR = Number of lost - time accidents 100,0000

Number of man - hours worked
Severity Rate (SR)
Total number of days lost
SR= 1,000
Total number of man - hours worked

25, The accident rate of two companies is different although they have the same size
workforce and produce identical products.
Outline possible reasons for this difference. (10)
Recognition of reportable accidents may differ
Differences in levels of reporting and recording accidents;
Definitions of the accident rate may be different or misinterpreted
Different calculating rates
Difference in the level of commitment;
Policies & procedures such as monitoring may be different
 Disciplinary procedures for non-compliance by
Workers may vary.
Differences in workplace layout and design
Age and type of equipment/machineries used;
Human resource issues (selection, training, competence, level of communication and
consultation);
Difference in risk assessments and associated control measures,
Existence of safe systems of work and procedures
use and maintenance of PPE;
piece work and shift work
winning of bonus payments which could lead to the taking of risks;
Cultural issues (attitude, motivation and behavior)
Peer Pressure