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Element A2 - OHS.me.uk · 2014-10-25 · LOSS CAUSATION ACCIDENT = Unplanned, uncontrolled event...

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Page 1: Element A2 - OHS.me.uk · 2014-10-25 · LOSS CAUSATION ACCIDENT = Unplanned, uncontrolled event (NOT the result) HSE – Accident = an event that results in injury or ill health

Element A2

Element A2

Page 2: Element A2 - OHS.me.uk · 2014-10-25 · LOSS CAUSATION ACCIDENT = Unplanned, uncontrolled event (NOT the result) HSE – Accident = an event that results in injury or ill health

LOSS CAUSATION

ACCIDENT =

Unplanned, uncontrolled event (NOT the result)

HSE –

Accident = an event that results in injury or ill health

Incident = Near Miss, undesired circumstance.

Near Miss = has potential to cause harm (incl D.O’s)

Undesired Circumstance = Set of conditions / circ’s that

have potential to cause injury or ill health.

HSG245 = Adverse Events Accidents

Incidents

Element A2

Page 3: Element A2 - OHS.me.uk · 2014-10-25 · LOSS CAUSATION ACCIDENT = Unplanned, uncontrolled event (NOT the result) HSE – Accident = an event that results in injury or ill health

LOSS CAUSATION

ACCIDENT RATIO STUDIES

Frank Bird – showed fixed ratio between losses of

differing severity (+ near misses)

Element A2

Page 4: Element A2 - OHS.me.uk · 2014-10-25 · LOSS CAUSATION ACCIDENT = Unplanned, uncontrolled event (NOT the result) HSE – Accident = an event that results in injury or ill health

LOSS CAUSATION

ACCIDENT RATIO STUDIES

HSE – (HSG96)

1 over 3 day

56+ Minor (first aid only)

3570+ Non injury acc

Uses

Learn from minor / n.misses to help prevent major

Helps convince – reporting – more opp’s to learn

Limitations

Not uniform throughout industry

Cultural and reporting differences

Element A2

Page 5: Element A2 - OHS.me.uk · 2014-10-25 · LOSS CAUSATION ACCIDENT = Unplanned, uncontrolled event (NOT the result) HSE – Accident = an event that results in injury or ill health

LOSS CAUSATION

DOMINO THEORY

HEINRICH

Series of events

Succession of events, follows logical pattern

FRANK BIRD

Modified theory

Element A2

Page 6: Element A2 - OHS.me.uk · 2014-10-25 · LOSS CAUSATION ACCIDENT = Unplanned, uncontrolled event (NOT the result) HSE – Accident = an event that results in injury or ill health

LOSS CAUSATION

DOMINO THEORY

FRANK BIRD

Modified theory:-

Loss –

Consequence of acc

People, prop, process, or potential loss of profit

Event

Acc or Inc

Element A2

Page 7: Element A2 - OHS.me.uk · 2014-10-25 · LOSS CAUSATION ACCIDENT = Unplanned, uncontrolled event (NOT the result) HSE – Accident = an event that results in injury or ill health

LOSS CAUSATION

DOMINO THEORY

FRANK BIRD

Modified theory:-

Immediate (direct) causes

Workplace hazards

Unsafe acts / conditions (symptoms)

Underlying (indirect) causes

Org / Proc / Job factors / Tech

Personal / Behaviour

Element A2

Page 8: Element A2 - OHS.me.uk · 2014-10-25 · LOSS CAUSATION ACCIDENT = Unplanned, uncontrolled event (NOT the result) HSE – Accident = an event that results in injury or ill health

LOSS CAUSATION

DOMINO THEORY

FRANK BIRD

Modified theory:-

Underlying (cont..)

Usually lack of MGT Control

Element A2

Page 9: Element A2 - OHS.me.uk · 2014-10-25 · LOSS CAUSATION ACCIDENT = Unplanned, uncontrolled event (NOT the result) HSE – Accident = an event that results in injury or ill health

LOSS CAUSATION

DOMINO THEORY

FRANK BIRD

Modified theory:-

Dealing with imm. Cause

Will only prevent this sequence

Dealing with all causes (esp ROOT)

Can prevent whole series of adverse events

AN IMPORTANT ASPECT IN LOSS CAUSATION /

PREVENTION

Thorough investigation to determine

root causes is necessary

Element A2

Page 10: Element A2 - OHS.me.uk · 2014-10-25 · LOSS CAUSATION ACCIDENT = Unplanned, uncontrolled event (NOT the result) HSE – Accident = an event that results in injury or ill health

LOSS CAUSATION

DOMINO THEORY

FRANK BIRD

Modified theory:-

Immediate cause

Less obvious “system” or “organisational” reason

E.g. checks are not carried out by supervisors

Root causes

Initiating event or failing

Generally MGT / Planning / Org failings

Element A2

Page 11: Element A2 - OHS.me.uk · 2014-10-25 · LOSS CAUSATION ACCIDENT = Unplanned, uncontrolled event (NOT the result) HSE – Accident = an event that results in injury or ill health

LOSS CAUSATION

DOMINO THEORY

FRANK BIRD

Modified theory:-

Multiple accident causes

Usually more than one causative factor in accident

DOMINO

Element A2

Page 12: Element A2 - OHS.me.uk · 2014-10-25 · LOSS CAUSATION ACCIDENT = Unplanned, uncontrolled event (NOT the result) HSE – Accident = an event that results in injury or ill health

LOSS CAUSATION

LATENT AND ACTIVE FAILURES

Latent = hidden

Accident

Train crash

Unsafe Acts (active failure)

Driver error

Pre Conditons (latent)

Tired, poor comm, faulty signal

Unsafe Supervison (latent)

Asked to work o/t

Organisational influences (latent)

Limited resources @ line MGT level

Element A2

Page 13: Element A2 - OHS.me.uk · 2014-10-25 · LOSS CAUSATION ACCIDENT = Unplanned, uncontrolled event (NOT the result) HSE – Accident = an event that results in injury or ill health

ANALYISIS OF DATA

AFR

Accidents compared with time

No of acc / total hrs worked x 1,000,000

Can be 100,000 or less to bring no’s to manageable size

AIR (accident incident rate)

Accidents compared with no of people

No of acc / Avg no employed x 10,000

Element A2

Page 14: Element A2 - OHS.me.uk · 2014-10-25 · LOSS CAUSATION ACCIDENT = Unplanned, uncontrolled event (NOT the result) HSE – Accident = an event that results in injury or ill health

ANALYISIS OF DATA

Accident Severity Rate

Avg no of days lost compared with hours worked

No of lost days / man hrs worked total x 1,000

Ill Health Prevalence rate

Similar to AIR but ill health not acc’s

No of ill health conditions / no of people exposed to

agent x 1000

Workplace or population

Element A2

Page 15: Element A2 - OHS.me.uk · 2014-10-25 · LOSS CAUSATION ACCIDENT = Unplanned, uncontrolled event (NOT the result) HSE – Accident = an event that results in injury or ill health

ANALYISIS OF DATA

Fatality

Won’t show up on severity rate – no lost time

Use all rates together

And compare using same definitions (100,000 etc)

Rise in rates

Not necessarily no improvement

Could be reporting rates are better therefore improved

culture

Must be carefully analysed

Easier to see trends in graphical or numerical format

Element A2

Page 16: Element A2 - OHS.me.uk · 2014-10-25 · LOSS CAUSATION ACCIDENT = Unplanned, uncontrolled event (NOT the result) HSE – Accident = an event that results in injury or ill health

REPORTING AND RECORDING

Stat req’s

RIDDOR 1995

Reports sent to relevant authority to compile stats and

show trends

To highlight problem areas in particular industries or

companies

Form F2508 within 10 days

Plus telephone if death or major injury (incl suicide)

Schedule 1 – Major injuries

Schedule 2 – D. Occ’s

Schedule 3 – Diseases

Element A2

Page 17: Element A2 - OHS.me.uk · 2014-10-25 · LOSS CAUSATION ACCIDENT = Unplanned, uncontrolled event (NOT the result) HSE – Accident = an event that results in injury or ill health

REPORTING AND RECORDING

Stat req’s

Accident Book (B1510)

Must be kept at location

Must be easily accessible at all reasonable times

Employer must then investigate

Records kept for 3 years

Element A2

Page 18: Element A2 - OHS.me.uk · 2014-10-25 · LOSS CAUSATION ACCIDENT = Unplanned, uncontrolled event (NOT the result) HSE – Accident = an event that results in injury or ill health

INTERNAL REPORTING / RECORDING

SYSTEMS

Relevant report forms

Accident book

First aid / med treatment book

Docs Reports

Sickness absence reports

Acc / Near miss reprots

RIDDOR reports (F2508)

Element A2

Page 19: Element A2 - OHS.me.uk · 2014-10-25 · LOSS CAUSATION ACCIDENT = Unplanned, uncontrolled event (NOT the result) HSE – Accident = an event that results in injury or ill health

INTERNAL REPORTING / RECORDING

SYSTEMS

Investigation reports

Level 1 – Line MGR

Level 2 – Other MGR / H+S Pract

Level 3 – Investigation team

What , How, Why, Recommendations…

Element A2

Page 20: Element A2 - OHS.me.uk · 2014-10-25 · LOSS CAUSATION ACCIDENT = Unplanned, uncontrolled event (NOT the result) HSE – Accident = an event that results in injury or ill health

INTERNAL REPORTING / RECORDING

SYSTEMS

Following fatality

Inform

Enforcing authority

SNR MGR

H+S Prac

Coroner

Next of kin

Reps

Other employees

Insurance company

Element A2

Page 21: Element A2 - OHS.me.uk · 2014-10-25 · LOSS CAUSATION ACCIDENT = Unplanned, uncontrolled event (NOT the result) HSE – Accident = an event that results in injury or ill health

INTERNAL REPORTING / RECORDING

SYSTEMS

Following fatality

Inform

Enforcing authority

SNR MGR

H+S Prac

Coroner

Next of kin

Reps

Other employees

Insurance company

Element A2

Page 22: Element A2 - OHS.me.uk · 2014-10-25 · LOSS CAUSATION ACCIDENT = Unplanned, uncontrolled event (NOT the result) HSE – Accident = an event that results in injury or ill health

LOSS INVESTIGATIONS

Not overtly stated in law…

…that accidents must be investigated

Implied – HASAW

Prevent reoccurrence

Investigate

Measures is place

HSG65

Ensures compliance on investigation requirements

Element A2

Page 23: Element A2 - OHS.me.uk · 2014-10-25 · LOSS CAUSATION ACCIDENT = Unplanned, uncontrolled event (NOT the result) HSE – Accident = an event that results in injury or ill health

LOSS INVESTIGATIONS

HSG 245

Step 1

Gather Info – where, when, who, interviews, photos etc

Step 2

Analyse info – what and why, consider human error (HSG48)

Step 3

Identify suitable risk control measures – solutions

Tech / eng more reliable than behaviour

Element A2

Page 24: Element A2 - OHS.me.uk · 2014-10-25 · LOSS CAUSATION ACCIDENT = Unplanned, uncontrolled event (NOT the result) HSE – Accident = an event that results in injury or ill health

LOSS INVESTIGATIONS

HSG 245

Step 4

Action Plan / Implementation – short term / long term

SMART

Specific

Measurable

Achievable

Realistic

Timescales

Element A2

Page 25: Element A2 - OHS.me.uk · 2014-10-25 · LOSS CAUSATION ACCIDENT = Unplanned, uncontrolled event (NOT the result) HSE – Accident = an event that results in injury or ill health

LOSS INVESTIGATIONS

PURPOSE OF INVESTIGATIONS

Discover underlying causes

Prevent re-occurrence

Establish legal liability

Data gathering

Identification of trends or patterns

NOT TO BLAME!!

Element A2

Page 26: Element A2 - OHS.me.uk · 2014-10-25 · LOSS CAUSATION ACCIDENT = Unplanned, uncontrolled event (NOT the result) HSE – Accident = an event that results in injury or ill health

LOSS INVESTIGATIONS

PURPOSE OF INVESTIGATIONS

If Human Error

Causes must be investigated

If lack of training or unsuitability for job -

MGT failings

If wilful / intentional acts

Human error

Element A2

Page 27: Element A2 - OHS.me.uk · 2014-10-25 · LOSS CAUSATION ACCIDENT = Unplanned, uncontrolled event (NOT the result) HSE – Accident = an event that results in injury or ill health

LOSS INVESTIGATIONS

WRITTEN REPORTS

Exec summary

Main body

Conclusions and recommendations

Remedial actions

Lessons learnt

Share best practice

Element A2


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