Int Dip Unit IA - Element IA2 - Loss causation and incident investigation
August 2012
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International
Diploma in
Occupational
Health and Safety
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INT DIP Unit IA 2nd Edition - Element IA2 - v.1.0 - Slide 1
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Second Edition August 2012.
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INT DIP Unit IA 2nd Edition - Element IA2 - v.1.0 - Slide 2
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NEBOSH
International
Diploma in
Occupational
Health and Safety
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INT DIP Unit IA 2nd Edition - Element IA2 - v.1.0 - Slide 3
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Unit IA
International
Management of
Health and Safety
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Loss causation and incident investigation
Learning outcomes
Element IA2
Loss causation
and incident
investigation
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IA2.1
IA2.2
IA2.3
IA2.4
Explain the 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 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
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Sample of PowerPoint presentation for NEBOSH International Diploma in Occupational Health and Safety
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Int Dip Unit IA - Element IA2 - Loss causation and incident investigation
August 2012
Loss causation and incident investigation
Loss causation and incident investigation
Contents
Contents
IA2.1
IA2.2
IA2.3
IA2.4
Theories of loss causation
Quantitative analysis of accident/incident and illhealth data
Reporting and recording of injuries, ill-health,
dangerous occurrences and near-misses
Loss and near miss investigations
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Loss causation and incident investigation
Theories of loss causation
IA2.1
IA2.2
IA2.3
IA2.4
Theories of loss causation
Quantitative analysis of accident/incident and illhealth data
Reporting and recording of injuries, ill-health,
dangerous occurrences and near-misses
Loss and near miss investigations
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Loss causation and incident investigation
Theories of loss causation
Accident/Incident/Near miss
• 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
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Loss causation and incident investigation
Theories of loss causation
• 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
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Accident/Incident
Near miss
Source: UK, HSG245.
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Loss causation and incident investigation
Theories of loss causation
Accident/incident ratio studies and their use and
limitations
• 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
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Sample of PowerPoint presentation for NEBOSH International Diploma in Occupational Health and Safety
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Int Dip Unit IA - Element IA2 - Loss causation and incident investigation
Loss causation and incident investigation
Theories of loss causation
August 2012
Loss causation and incident investigation
Theories of loss causation
Accident/incident ratio studies and their use and
limitations
Accident/incident ratio studies and their use and
limitations
Accident ratio study
Accident ratio pyramid
Source: Frank Bird.
Source: UK, HSG96 the costs of accidents at work.
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Loss causation and incident investigation
Theories of loss causation
Accident/incident ratio studies and their use and
limitations
Accident ratio triangle
Source: OGP, International Association of Oil & Gas Producers.
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Accident/incident ratio studies and their use and
limitations
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
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Loss causation and incident investigation
Theories of loss causation
Accident/incident ratio studies and their use and
limitations
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
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Loss causation and incident investigation
Theories of loss causation
Loss causation and incident investigation
Theories of loss causation
Domino and multi-causality theories
• 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
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Sample of PowerPoint presentation for NEBOSH International Diploma in Occupational Health and Safety
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Int Dip Unit IA - Element IA2 - Loss causation and incident investigation
Loss causation and incident investigation
August 2012
Loss causation and incident investigation
Theories of loss causation
Theories of loss causation
Domino and multi-causality theories
The domino theory
Accident causation domino
Domino and multi-causality theories
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.
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Loss causation and incident investigation
Loss causation and incident investigation
Theories of loss causation
Theories of loss causation
Domino and multi-causality theories
The domino theory
Accident causation domino
Domino and multi-causality theories
•
•
•
•
Loss
Event (accident/incident)
Immediate (direct) causes
Underlying (indirect or root) causes
- Organisational factors (Procedural)
- Job factors (Technical)
- Personal factors (Behavioural)
Source: Frank Bird - ILCI.
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Loss causation and incident investigation
Theories of loss causation
Domino and multi-causality theories
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Loss causation and incident investigation
Theories of loss causation
Domino and multi-causality theories
Sequence of dominoes
Lack of management control
• Policy
• Planning
• Organising
• Controlling
• Monitor
• Review
Source: UK, HSG245.
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Sample of PowerPoint presentation for NEBOSH International Diploma in Occupational Health and Safety
4
Int Dip Unit IA - Element IA2 - Loss causation and incident investigation
Loss causation and incident investigation
August 2012
Loss causation and incident investigation
Theories of loss causation
Theories of loss causation
Domino and multi-causality theories
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)
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
Source: RMS.
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Loss causation and incident investigation
Theories of loss causation
Loss causation and incident investigation
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/incident model
Source: Reason/RMS.
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Loss causation and incident investigation
Contents
IA2.1
IA2.2
IA2.3
IA2.4
Theories of loss causation
Quantitative analysis of accident/incident and illhealth data
Reporting and recording of injuries, ill-health,
dangerous occurrences and near-misses
Loss and near miss investigations
Copyright RMS Publishing
INT DIP Unit IA 2nd Edition - Element IA2 - v.1.0 - Slide 29
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Part only of the complete
Element IA2 - Loss
causation and incident
investigation
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260605
Sample of PowerPoint presentation for NEBOSH International Diploma in Occupational Health and Safety
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