Losscausationandincidentinvestigation

Lossmakingevents(injuriesresultingfromaccidentsinourcase)havevariouscauseswhichcanbe
placedintotwogroups:

ImmediateCauses
Thecutwascausedbyasharpedgeontheworkpiece,thebackstrainwascausedbyliftingaboxthat
wastooheavy.Thisisoftenasfarasaproductionmanageroralinemanagerwillinvestigateand
hopefullytheoperatorwillremembertowearglovesorgetahandliftingtheboxnexttimebutthese
immediatecauseshaveunderlyingcauseswhichshouldbeinvestigatedinordertogettotherootcauses
ofalossmakingevent.

UnderlyingCauses
Thesharpedgeontheworkpieceshowsafailureofthemanufacturingprocess,toremovesharpedges,
theoperatordidn'tknowthattheyshouldweargloves,theoperatordidn'thaveglovesanddidn'tknow
wheretogetthem,theglovessuppliedwerenotuptothetask,theoperatorknewthatgloveswere
neededbutwasintoomuchofahurrytogetapairortoputthemon...yougettheideaI'msure.
Ifwefixanimmediatecause(e.g.removingthesharpedge)thennooneelsewillbeinjuredbythat
edgeonthatworkpiece,butwilltherebeasharpedgeonthenextworkpieceandmoreinjuries?
Ifwefixtheunderlyingcausesofanaccidentthenwepreventthattypeofaccidenthappeningagain
andsobenefitfromfewerinvestigationstodointhefuture,aswellasalltheotherbenefitsofgood
healthandsafetymanagement.

AlongtimeagoamanbythenameofHeinrichpublishedhisdominotheoryaboutwhatcauses
accidents.ThigsweredifferentbackthenanditwasOKtosaythingslikeohit'stheircultureyou
know.Heinrichthoughtinstraightlinesandwasabitblinkeredinhisapproachsothereareonlyfive
logicallyorderedstepsinhismodelofhowlosseventshappen:

Ancestry/Social FaultofPerson UnsafeAct/ Accident Injury

Environment UnsafeCondition
ThisisveryunPC FitsofAnger,Reckless Knowlinglytaking Cutting,Crushing, Fractures,Cuts,
butHeinrichbelieved Behaviour, risks,Refusingtotake Tripping,Slipping, Bruises,Broken
thatcharactertraits Nervousness, precautions,Removing Fallingoffladders,etc Bones,Death
suchasstubborness, Excitability guards,Not
recklessness,etccould maintaining
bepasseddown housekeepingstandard,
genetically(Ancestry) etc
andsocially.Healso
believedthatlackof
education
(Environmental)might
alsoleadtothesetraits
(whichisabitmore
PC)
Ifyoucanpreventoneofthestepsfromhappeningthenthatstopsthewholeprocess,theeasiestoneto
stopistheunsafeactormechanical/physicalhazardalthoughthereissomefocusnowbeingplacedon
environmentalcausesthrougheducationandadvertisingawarenesscampaigns.

AlittlelateronBirdandLoftusdevelopedHeinrich'stheoryandbroughtouttheirowntheoryofwhy
lossmakingeventsoccurandhowtopreventthem.Thiswasstillquitesimplisticinthatitwasstillone
straightline,howeveritdidincludemanagementfailuresasstepsintheprocesstoalossmakingevent,
andthiswasarevelation.Thisisthebasisoflosscontrolmanagmentandcanbeappliedineverycase.
Management BasicCauses Substandard Accidents Injuries
FailuretoControl (PersonalandJob Conditions,
Factors) Errors
Puttingproduction Untrainedemployees, Knowlinglytaking Cutting,Crushing, Fractures,Cuts,
beforesafety,failingto routineviolations(lack risks,Refusingtotake Tripping,Slipping, Bruises,Broken
assessrisksproperly, ofdiscipline), precautions,Removing Fallingoffladders,etc Bones,Death
failuretoimplement uncorrectederrors,etc guards,Poor
controlmeasures,poor housekeepingstandard,
H&Sculture etc

Followingonfromthiscamemulticausalitytheory,whereitwasrecognisedthatonelossmakingevent
couldhaveseveralrootcauseswhich,whentheycometogether,resultinalossmakingevent.For
insanceinorderforafiretooccurseveralthingsneedtohappenatonce.
1. Fuelhastobepresent
2. Oxygenhastobepresent
3. Thefuelandoxygenhavetobeinthecorrectproportionstoignite
4. Asourceofignitionhastobepresent.
Ifanyofthesethingsarenottrue,thefireshallnothappen.Soinordertoinvestigateafirewehaveto
checkforallsourcesofignition,allsourcesoffuel,andallsourcesofoxygen(althoughitisusually
presentintheatmosphere).
AmultiplecauseinvestigationresultsinadiagramsimilartothatusedforFaultTreeAnalysisandeach
possiblecausemustbeanalysedtofindrootcauses.

AtthispointyoushouldreadHSG245whichgoesintogreatdetailaboutaccidentinvestigationand
providesseveralexamples.