Element IA2: Loss Causation and incident investigation

Transcription

1 Element IA2: Loss Causation and incident investigation 1.Outline the five factors in Heinrich s 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 Heinrich s? 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.

2 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.

3 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 frontline 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 Reason s 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.

4 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 don t 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

5 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 person s 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.

6 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

7 (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?

8 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.

9 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 campaign s 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 organisation s 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

10 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

11 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

12 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