Diploma Unit A - Element A2 - Loss causation and incident investigation
NEBOSH DIPLOMA
IN OCCUPATIONAL HEALTH AND
SAFETY
February 2014
LICENCE DETAILS
RMS Publishing
Victoria House, Lower High Street, Stourbridge DY8 1TA
© RMS Publishing.
Unit A
Fifth Edition November 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.
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.
Managing health and safety
Issued to:
Single Licence
Licence No:
1
ELEMENT A2
LOSS CAUSATION AND INCIDENT
INVESTIGATION
2
LEARNING OUTCOMES
A2.1
A2.2
A2.3
A2.4
Explain theories of loss causation
Explain the quantitative analysis of accident/incident
ill-health data, limitations of their application, and
their presentation in numerical and graphical form
Explain the statutory and the internal reporting and
recording systems for injuries, ill-health, dangerous
occurrences and near-misses
Explain loss investigations; the requirements,
benefits, the procedures, the documentation, and
the involvement of and communication with relevant
staff and representatives
3
4
CONTENTS
CONTENTS
A2.1
A2.2
A2.1
A2.2
A2.3
A2.4
Theories of loss causation
Quantitative analysis of accident and ill-health
data
Reporting and recording of injuries, ill-health,
dangerous occurrences and near-misses
Loss investigations
A2.3
A2.4
Theories of loss causation
Quantitative analysis of accident and ill-health
data
Reporting and recording of injuries, ill-health,
dangerous occurrences and near-misses
Loss investigations
5
Sample of PowerPoint presentation for NEBOSH National Diploma in Occupational Health and Safety
6
1
Diploma Unit A - Element A2 - Loss causation and incident investigation
February 2014
Theories of loss causation
ACCIDENT/NEAR MISS
Theories of loss causation
• Losses result from lack of control
• Revealed by loss causing events ‘accident’
• 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, but rather as the results of accidents
Accident
Near miss
Source: HSG245.
7
8
Theories of loss causation
Theories of loss causation
• Difference between a near miss and a fatal accident 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 accidents (i.e. the result or
consequences).
• An old adage says never waste an accident
• Every accident 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
• HSG245 “Investigating accidents and incidents”
• An adverse event includes accidents and incidents
• The term ‘adverse event’, as used by the HSE is similar to
the term ‘accident’ and encompasses events that have a
wide range of outcomes
• The HSE reserve the term ‘accident’ for events that involve
harm to people
• The HSE define an Accident as:
An event that results in injury or ill-health
9
10
Theories of loss causation
Theories of loss causation
ACCIDENT RATIO STUDIES AND THEIR USE
AND LIMITATIONS
ACCIDENT RATIO STUDIES AND THEIR USE
AND LIMITATIONS
• Some years ago, a study of 1,750,000 accidents, in 21
industry sectors, led by Frank Bird, showed that there is a
fixed ratio between losses of different severity (and
accidents where no loss occurred, i.e. near misses)
• This can be demonstrated with a pyramid model
Accident ratio study
Source: Frank Bird.
11
Sample of PowerPoint presentation for NEBOSH National Diploma in Occupational Health and Safety
12
2
Diploma Unit A - Element A2 - Loss causation and incident investigation
February 2014
Theories of loss causation
Theories of loss causation
ACCIDENT RATIO STUDIES AND THEIR USE
AND LIMITATIONS
ACCIDENT RATIO STUDIES AND THEIR USE
AND LIMITATIONS
Accident ratio pyramid
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 Bird model includes property damage in addition to near
misses
• The 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
Source: HSG96 the costs of accidents at work.
13
14
Theories of loss causation
Theories of loss causation
ACCIDENT RATIO STUDIES AND THEIR USE
AND LIMITATIONS
DOMINO AND MULTI-CAUSALITY THEORIES
Limitations
• Bird’s findings are not uniform throughout industry
• The accident 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 time-frame, to
be effective
• In smaller organisations, the first recorded accident may be the top
event, i.e. fatality or major injury
• Near miss reporting may mean different things to different people
• HW Heinrich proposed one of the first coherent theories of
accident causation in the mid 1920s
• Suggested that accidents 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
15
16
Theories of loss causation
Theories of loss causation
DOMINO AND MULTI-CAUSALITY THEORIES
DOMINO AND MULTI-CAUSALITY THEORIES
The domino theory
Accident causation domino
The domino theory
• Further research by the International Loss Control Institute
(ILCI) into accident causation led them to put forward a
modified domino theory
Source: H.W. Heinrich.
17
Sample of PowerPoint presentation for NEBOSH National Diploma in Occupational Health and Safety
18
3
Diploma Unit A - Element A2 - Loss causation and incident investigation
February 2014
Theories of loss causation
Theories of loss causation
DOMINO AND MULTI-CAUSALITY THEORIES
DOMINO AND MULTI-CAUSALITY THEORIES
The domino theory
Accident causation domino
•
•
•
•
Loss
Event
Immediate (direct) causes
Underlying (indirect or root) causes
- Organisational factors
- Job factors
- Personal factors
Source: Frank Bird - ILCI.
19
20
Theories of loss causation
Theories of loss causation
DOMINO AND MULTI-CAUSALITY THEORIES
DOMINO AND MULTI-CAUSALITY THEORIES
Lack of management control
• Policy
• Planning
• Organising
• Controlling
• Monitor
• Review
Sequence of dominoes
Source: HSG245.
21
22
Theories of loss causation
Theories of loss causation
DOMINO AND MULTI-CAUSALITY THEORIES
LATENT AND ACTIVE FAILURES - REASON’S
MODEL OF ACCIDENT CAUSATION
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)
• 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
• 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
Source: RMS.
23
Sample of PowerPoint presentation for NEBOSH National Diploma in Occupational Health and Safety
24
4
Diploma Unit A - Element A2 - Loss causation and incident investigation
February 2014
Theories of loss causation
Theories of loss causation
LATENT AND ACTIVE FAILURES - REASON’S
MODEL OF ACCIDENT CAUSATION
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
J. Reason’s accident model
Source: Reason/RMS.
25
26
Quantitative analysis of accident and ill-health data
CONTENTS
METHODS OF CALCULATING INJURY RATES
FROM RAW DATA
A2.1
A2.2
• Accident frequency rate: number of accidents over time
• Accident incident rate: number of accidents compared with
number of people
• Accident severity rate: average number of days lost
compared with hours worked
• Ill-health prevalence rate: similar to incidence rate but is an
index of ill-health rather than accidents
A2.3
A2.4
Theories of loss causation
Quantitative analysis of accident and ill-health
data
Reporting and recording of injuries, ill-health,
dangerous occurrences and near-misses
Loss investigations
27
28
ELEMENT A2
LOSS CAUSATION AND INCIDENT
INVESTIGATION
Quantitative analysis of accident and ill-health data
METHODS OF CALCULATING INJURY RATES
FROM RAW DATA
• These calculations are made from the actual numbers of
accidents, hours worked, numbers employed and days lost
• In order for the result to be a meaningful number, a large
multiplier is included in the equation
• The injury rates only mean something if they are compared
to other injury rates and are to be used to show trends
• May be compared to rates from previous years, to rates
from other departments in the company, to other companies
or to rates in a particular industry
PART ONLY
SAMPLE
29
Sample of PowerPoint presentation for NEBOSH National Diploma in Occupational Health and Safety
30
5