Incident Causation Theory.pdf

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ACCIDENT AND INCIDENT INVESTIGATION

INCIDENT CAUSATION ANALYSIS METHODOLOGY (ICAM)FACTORS INFLUENCING OCCURENCE OF INCIDENTS

THE CAUSATION PATHWAY

Written by Nigel Pitt IMORSA.com


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Incident Accident Investigation - Causation Pathway June 13, 2013

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TABLE OF CONTENTS

TABLE OF CONTENTS 1

SECTION ONE: CAUSES AND CONSEQUENCES OF INCIDENTS 2

SECTION TWO: STATISTICS 3

SECTION THREE: COSTS OF ACCIDENTS 4

SECTION FOUR: PROBABILITY AND LIKELIHOOD 5

SECTION FIVE: MANAGEMENT 6

SECTION SIX: DEFINITIONS 7

SECTION SEVEN: CONTROLLING POTENTIAL INCIDENTS 9

SECTION EIGHT: INCIDENT CAUSATION THEORY 11

SECTION NINE: CAUSATION MODEL 12

SECTION TEN: IDENTIFY THE ABSENT OR FAILED DEFENCES 15

SECTION ELEVEN: IDENTIFY THE INDIVIDUAL / TEAM ACTIONS 16

SECTION TWELVE: IMMEDIATE CAUSES 19

SECTION THIRTEEN: IDENTIFY THE TASK / ENVIRONMENTAL CONDITIONS (Underlying Causes) 20

SECTION FOURTEEN: MANAGEMENT CONTROL 22

SECTION FIFTEEN: RISK ASSESSMENTS 24


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SECTION ONE: CAUSES AND CONSEQUENCES OF INCIDENTS

WHY DO ACCIDENTS HAPPEN?

Accidents dont happen they are caused. Many accident investigations reflect the lack of management control and subsequent

consequences. Where effective management control is lacking there are exposures in the work place. Safety in the work place is

managed by the imposition of policies, rules, regulations, standards, practices, procedures, systems of work, guidelines,

specifications and codes of practice.

Consider the following and their effect on maintaining a safe work place and systems of work:

Lack of leadership, lack of resources, urgency, poor training, lack of compliance, lack of roles responsibilities and accountabilities,

inadequate risk assessments and inadequate Job safety plans, inadequate or noncompliance with procedures, lack of

competence, production focus a priority, lip service to safety, superficial safety culture, no application of standards,

organisational culture, inadequate audits, inadequate inspections and reviews, inadequate contractor management and

oversight etc.

The failure to comply with systems of work and controls cause most of the incidents. Incident investigations enable the

identification of how and why these system failures occur, their consequences and what needs to be done to prevent

recurrence.

WHY INVESTIGATEACCIDENTS? By identifying the real causes, a similar or perhaps more disastrous incident may be prevented in future provided proper and

effective corrective measures are implemented.

Viewing the incident as "the consequence of a failure or inadequacy in the safety management system" engenders professional

investigative efforts. Identifying a failure in the system will assist with directing one towards uncovering meaningful information

regarding the incident.

CONSEQUENCE

Consequence essentially is the final outcome of an event. It is the collective sum of all the issues that the organisation will be

confronted with after the event, i.e. after the accident has happened. Consequences might be management intervention

strategies, reputational issues, restructuring, litigation, multiple fatalities, dismissals, official enquiry, prosecution, closure of

operation, shares devalued, fines, penalties and imprisonment, etc. The degree of severity would be relative to the measure as

determined by the organisation. It would relate to the number of people affected, the area affected, the magnitude of the loss

incurred and the degree of violation of statutory requirements and dependant on the view the judiciary would take given the

seriousness of the offence, etc.

BP agrees to pay largest penalty in US history in $4.5bn Gulf oil spill deal

Oil giant BP will pay $4.5bn to US authorities and agrees to plead guilty to 11 felony counts of misconduct over fatal rig

explosion.

BP has agreed to pay the largest criminal fine in US history $4.5bn to resolve all criminal charges arising from the fatal oil rig

explosion and catastrophic oil spill in the Gulf of Mexico.
http://www.guardian.co.uk/environment/oilhttp://www.guardian.co.uk/environment/oil


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SECTION TWO: STATISTICS

FRANKBIRDSTUDY: THE ACCIDENT PYRAMID

In order to understand the history of incident prevention, one needs a good understanding of what it takes to reduce injuries.

The accident pyramid model used many years ago will provide some useful information and assist with understanding.

In 1969, a study of industrial accidents was undertaken by Frank E. Bird, Jr., who was then the Director of Engineering Services

for the Insurance Company of North America. He was interested in the accident ratio of 1 major injury to 29 minor injuries to

300 no-injury accidents first discussed in the 1931 book, Industrial Accident Prevention by H. W. Heinrich. Refer to Figure 1.

Figure 1: Safety Pyramid Developed by H.W. Heinrich (1931)

For every reported major injury (resulting in fatality, disability, lost time or medical treatment), there were 9.8 reported minor

injuries (requiring only first aid). For the 95 companies that further analysed major injuries in their reporting, the ratio was one

lost time injury per 15 medical treatment injuries. Refer to Figure 2.

Figure 2

In 1993 the Health and Safety Executive (HSE) group of the British government published the results of one of its studies. The

study was conducted by a team of professionals, including economists, who visited five different locations representing different

industry types.

Other interesting findings of the British research include: 37% of an organisations annual profit was lost due to incident costs. The equivalent of 8.5% of organisations total annual revenue was lost due to incident costs. The equivalent of 5% of an organisations operating budget was lost due to incident costs. Although there was a wide range of immediate causes for the incidents, there were very common underlying causes. A separate analysis of 80% of the incidents showed that over 8% had the potential to have serious or major

consequences.

Considering these studies, it is evident that there is a fundamental relationship between major incidents, minor incidents, and

near-misses. This infers that efforts directed at events where there is no consequence are more effective than focusing primarily

on serious incidents. Focusing on consequences is reactive not proactive.

Evidence suggests that there are more minor incidents than serious incidents in the work place. This confirms the merits ofgiving attention to the less serious incidents so that the causes can be identified and corrected before more serious incidents

occur.


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SECTION THREE: COSTS OF ACCIDENTS

There is a direct relationship between direct costs (1) and all the hidden costs (6-53) that arise at a later stage that are not

immediately noticeable when an accident occurs. The costs of incidents can be illustrated as an iceberg, illustrated above.

The relatively low costs associated with insurance and medical expenses are obvious, like the tip of the iceberg, while theenormous overall costs of incidents are to be found below the surface.

It will be noticed by reviewing the iceberg that for every 1 unit of costs, there are 6 to 53 times that amount of loss due to

property, environment, assets, reputation, process, material, and miscellaneous cost.

These numbers have been derived by researching insurance cost data which supports that the costs of losses reported in the

transportation industry (e.g. trucking and railroad), and various manufacturing industries alone is many times the national costs

of work related injuries and illnesses.

In addition, there have been numerous case studies, involving single sites or companies, which have since been done, which

support these numbers as well. For capital-intensive operations the costs tend to be high; whereas for labour-intensive

operations they tend to be relatively low. These costs must be carefully monitored or they will go unnoticed.

There are various costs associated with incidents. Some are obvious while others are less obvious such as:

Business opportunities foregone

Corporate brand, image and reputational issues

Criminal prosecution

Employee morale and commitment

Future leverage opportunities

Investigation and inquiry costs

Loss of investor confidence

Market share loss

Pain, suffering and anguish

Psychological trauma on employees

Public relations


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Costs can broadly be categorised under the following headings:

Compensation and

BenefitsOperational costs Miscellaneous Legal/Litigation Process/Production

Death benefits Capital expenditures Advisory feesAttorney and legal

counsel feesCleaning materials

Long term disabilityEquipment

replacement

Hired plant and

machinery costs

Fines, penalties, and

citations

Defect production

costs

Medical and

rehabilitation

Loss of customers

and returned

products

Labour hire costs Labour/Union costs Equipment repair

Pension benefits and

lump sum payments

Process / downtime

and lossMarketing Settlements Laboratory costs

Wages for hired

labour

Rental costs for

replacement

equipment

PRSubject matter

expertsManagement time

Facility recovery Outsourcing Third party claims Overtime

Start-up costs Investigation fees Prosecution Retraining

Product recall Salvage and clean-up

Material recovery

SECTION FOUR:PROBABILITYAND LIKELIHOOD

Likelihood is the hypothetical probability that an event that has already occurred would yield a specific outcome.

The concept differs from that of a probability in that a probability refers to the occurrence of future events, while likelihood

refers to past events with known outcomes. I.e. it has happened in the industry or company before.

These factors affect the degree of likelihood of an occurrence of an event.

The probability of loss occurring whenever a particular task is performed is determined by the following factors:

Hazardousness (i.e. how inherently dangerous is the task).

Difficulty (i.e. is the task prone to quality, production or other problems?)

Complexity of the task.

The chance that loss will be incurred if the task is performed improperly.
http://mathworld.wolfram.com/Probability.htmlhttp://mathworld.wolfram.com/Probability.html


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SECTION FIVE:MANAGEMENT

INTRODUCTION

World class organisations have established core fundamentals related to safety, one of which is that safety is a line management

responsibility. This philosophy is entrenched in PDO HSE management responsibilities. This infers that top management is

responsible for the overall establishment, implementation and maintenance and ultimately the performance of the safety

management system. This begs the question Who is Management?

MANAGEMENT

Given that people are generally involved in incidents, either directly or indirectly, it is appropriate that one understands the term

Manager. Managers are responsible for managing organisational system processes and it is the failure of these management

system processes that needs to be identified.

Managers are the people responsible for enabling an organisation to achieve its stated goals and objectives.

Managers are responsible for the process of planning; organising; leading, coordinating and controlling the efforts of

organisational members and using all organisational resources at their disposal to achieve stated organisational goals. (Mescon

et al., 1985)

This explains what managers do:

Managers require skill and this management skill is explained as getting things done by other people (Parker Follett, 1941).

Furthermore, it can be said that the activity of management is the process of optimising personal, material, and financial

contributions for the achievement of organisational goals (Mescon et al, 1985).

WHAT MANAGERS DO

Fayol defined the following management functions:

Planning: the activities necessary to ensure the achievement of the stated organisational objectives

Organising: to ensure the availability and coordination of the material and personal resources within the organisational business

units necessary to accomplish the organisational goals

Leading: providing direction to employees

Controlling: involving the process of monitoring and adjusting organisational activities in order to facilitate the accomplishment

of organisational objectives

Coordinating: ensuring the organisational resources and activities work together to achieve stated goals.


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SECTION SIX: DEFINITIONS

MEANING OF INCIDENT

An unplanned and undesired event or chain of events that has, or could have, resulted in injury or illness, damage to assets,the environment, company reputation, and/or consequential business loss.

or

the release or near release of a hazard, which exceeds a defined limit or threshold limit value.

MEANING OF MAJOR INCIDENT

Unplanned event which does result in injury, harm and damage

MEANING OF HIGH POTENTIAL INCIDENT (HiPo)

An Incident or unsafe/unhealthy condition or near miss where the most serious probable outcome is a Major Incident.

A HiPo may not be identified as such at the time of the Incident and it is only after investigation that the true severity of the

most serious probable outcome becomes clear. If, after investigation, an incident is found to fit these definitions, it should be

reported as a HiPo, even if it is outside the nominated reporting timeframe

It is critical that one understands the characteristics of an accident if one is to prevent them from occurring again.

For an accident to be an outcome of an event there has to be damage of some degree. If a person cuts his/her finger on a paper

cutter it is an accident. As minor as it may be, an injury is sustained. Where a serious incident occurs resulting in severe injury,

illness, harm or damage there has to be some contact with a source of energy or substances which exceed the resistive limit of

the body, structure or environmental media.

Energy is found in different forms such as chemical, electrical, thermal, kinetic, noise, radiation and potential energy, etc.

(page13)

The following examples illustrate an accident:

An electrician and his assistant were assigned the task of repairing a three phase supply to a pump station. The electrician

wanted to determine if there was supply on the load side of the distribution point and attempted to test one of the phases in

the main circuit breaker. In so doing he placed the tip of the probe of the multimeter between two of the phase lugs causing a

short circuit and a flash over. The consequence was serious burn injuries and a burnt out MCB.

The driver of a bulk fuel tanker fell asleep behind the wheel, resulting in the vehicle capsizing and spilling the contents of three

of the compartments, thereby contaminating the soil and resulting in a fire and fatality.

It is clear from the above that one incident is more severe than the other.


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MEANING OF NEAR MISS

An unplanned event that did not result in injury, illness, or damage to assets, the environment or Company reputation but

had the potential to do so.

Or

An incident which under slightly different circumstances could have resulted in injury, harm or damage.

A near miss is an event where there is no undesirable consequence or outcome, i.e. no injury, harm, damage or illness is

sustained. It is typically an event where had there been a minor variation in circumstances the event would have resulted in an

accident rather than a near miss. Where these events occur one must consider the possibility of the outcome having been worse

and consider the worst case scenario. Where the potential exists for the consequences to have been severe one should

investigate the incident as if it had occurred and resulted in the worst possible outcome.

MEANING OF UNSAFE ACT/CONDITION

Any departure from the required or expected performance or condition of equipment (Plant), procedures (Process), or People

(conduct), which if not addressed could result in an Incident, or make a consequence of an incident more severe.

MEANING OF LOSS

Loss in environmental terms may be defined as avoidable waste of a resource.

Loss in terms of safety is defined as avoidable harm to people, the environment, assets, reputation, systems and process.

MEANING OF SAFETY

Control of accidental losses to an acceptable level

Judgement of the acceptability of risk

The minimisation of loss

MEANING OF CRITICAL FACTORS:

Negative actions or undesirable conditions that influence the course of events.

Major contributions to the incident. How did this event cause the incident. Why?

Actions or conditions, which if eliminated, would have either prevented the occurrence or reduced its severity.


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SECTION SEVEN: CONTROLLINGPOTENTIAL INCIDENTS

PHASES

When one conducts an investigation into an accident and determines the time line of events prior to the critical event occurring

that resulted in an accident one realises that there were contributing factors prior to the critical event occurring, the critical

event itself and post event issues i.e. consequences and emergency response etc. The accident investigation focuses on all the

evidence supporting events leading up to the critical event.

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The Phases of control are explained by reference to pre-contact, contact and post contact control opportunities.

Therefore:

Pre-contact control; offers opportunities to safeguard against the occurrence of the event,Contact control; offers opportunities to minimise the severity of the impact, andPost contact control; offers opportunities to safeguard against additional losses and mitigate to make less severe the current

circumstances.


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CONTROLAT THE PRE-CONTACTPHASE

In the pre-contact phase one needs to consider the effectiveness of implemented barriers and defences which are the

physical and procedural control processes such as policies, rules, regulations, standards, engineering practices, procedures,

systems of work, legislation etc. These control processes are necessary to minimise the threats, system or equipment failures,

i.e. latent or active failures, and should have evolved out of a hazard identification and risk assessment process.

CONTROLAT THE CONTACT PHASE- BEFORE THE ACCIDENT Control at this stage would require considering numerous options at ones disposal in order to minimise the consequences of

any impact. What measures were taken to minimise the initial impact?

reducing the amount of energy used or released

reducing rotational speeds

reducing flow rates

reducing high pressure to low pressure

raising the flashpoint of substances

reducing high voltage to low voltage

reducing thermal values

reducing volumes of stored chemicals

placing barriers at point of exposure

access control

bunding

cages

explosion bunkers

fire walls

fume cupboards

machine enclosures

machine guarding

fire resistant suits and equipment

separator pits and sumps

engaging alternative energy sources or substituting with less

harmful substances

use of non-flammable substances

reduction of toxicity exposure levels in substances ormaterials

replacing manual labour operations with automated systems

modify contact surfaces

install anti slip tread material

install bollards

roughen surfaces

smoothing edges

strengthening body or structure

reinforcing structures

case hardening of tool parts

reinforce glass with film shield protection

CONTROLAT THE POST CONTACT PHASE RECOVERY AFTER THE ACCIDENT.

The extent of any loss can and should be controlled to ensure that the loss does not escalate into an uncontrolled state

resulting in even greater loss. For example, a fire in a gasification plant in a refinery needs to be contained otherwise the end

result could be devastating. This control should ideally be achieved by means of proper crisis management or emergency

response procedures and standards.

This might include amongst other things:

Appropriate training

Back-up equipment (e.g. pumps, foam systems,

generators, lights, etc.)

Disaster management plans

Emergency control facilities

Emergency response organisationsExternal support

Medical response teams and facilities

Proto teams

Rescue equipment

Scenario drills

Spill prevention and control

Well-developed emergency response/crisis managementplans and procedures.


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SECTION EIGHT:INCIDENT CAUSATION THEORY

The purpose of accident investigations is to identify those direct and underlying causes that lead to accidents.

The ICAM system used here relates to SCAT Systematic Causal Analysis Technique. It is essentially a guide used to direct one

through the causation process systematically enabling one to identify the underlying cause of the problem.

UNDERLYINGCAUSE

An underlying cause is an initiating cause of a causal chain of events which leads to an outcome or an undesirable effect of

interest. The term underlying cause is used to describe the depth in the causal chain where an intervention could reasonably

be implemented to change performance and prevent an undesirable outcome.

COMPONENTSOF UNDERLYINGCAUSE ANALYSIS

PL ANT/E QU I P M E NT/M ACH I NE RY /TOOL S /FACI L I TI E S

incorrect tool selection

inadequate maintenance or design

inadequate equipment or tool placement

defective equipment or tool

work environment

disorderly workplace

surfaces poorly maintained

excessive physical demands of the task

MATE R I AL S

defective raw material

incorrect material for process

absence of raw material

material not to specification

MAN AG E ME NT

lack of or poor standard of management involvement

inattention to task

inadequate work planning

inadequate supervision

inadequate training or education

inadequate enforcement of rules

psycho social stress

ME TH OD S

inadequate procedures

inadequate guarding

inadequate process

non-conformance practices (actions) with procedures

inadequate communication

MAN AG E ME NT SY ST E MS

inadequate systems

inadequate implementation

inadequate compliance

inadequate roles and responsibilities

inadequate standards

inadequate recognition of hazards

inadequate hazard identification and risk assessment


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SECTION NINE: CAUSATION MODEL

The causation model is a tool which enables one to follow a logical route necessary to determine underlying causes and

conclude a successful investigation. It represents the sequence or stages of events that lead to incidents and is a graphical

representation of the theory of causation.

The Incident Causation Model is best understood working from the loss section to the Risk Management and Compliance

section. This enables one to understand the sequence of events leading up to the loss. A diagram is used to facilitate a better

understanding of the relationship between the various aspects of causation as shown below.

For example, a loss was incurred due to a contact (the incident event) with an energy source or substance (hazard) due to a

failed barrier, (control) due to immediate causes, (unsafe acts/conditions) emerging from (basic) underlying causes produced

by system defects as a consequence of inadequate management control.

MULTIPLE CAUSATION

Loss causation theory requires the understanding of the multiple causation theory which states that there are multiple causes

underpinning every incident. These multiple causes interact collectively to cause the incident. Once the causation sequence is

set in motion, it is unknown as to what the eventual outcome will be. This is best understood when one considers the domino

theory. If a number of dominos are aligned and the first domino is tipped, the rest will fall until the last one tumbles.


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LOSS

When an event happens in an organisation and the energies involved exceed the limitations of tolerance of a body or media to

resist the effect of the energy on the body often the consequences result in a loss. When a loss is incurred as a consequence of

an incident type event occurring it is termed an accident. These losses manifest (apparent) themselves in terms of injuries,

illness, harm and damage. They affect people, the environment, assets (tools, plant, equipment, machinery, materials) and

reputation, directly i.e. people are injured and become ill, the environment is harmed, and tools, plant, equipment, machinery

and facilities are damaged, thereby affecting process and reputation.

Harm to People: is the most serious of consequences and warrants the highest level of attention from Management.

There are tangible losses associated with injuries (such as trauma, disfigured bodies, compensation costs, rehabilitation costs,

absenteeism, overtime costs etc.) as well as personal costs (such as anguish, stress, suffering, psychological trauma, pain, poor

morale, etc.)

Harm to Environment: includes any negative impact on the environment that the organisations aspects may present

Harm to Assets: includes tools, plant, equipment, machinery, facilities, materials, and parts damage.

Harm to Reputation: is often overlooked, yet represents one of the most serious consequences that many organisations never

recover from. Consider that BP will never recover their reputation from the Texas City refinery explosion and Deep Water

Horizon disaster (Macondo Blow Out)

INCIDENT

The incident or potential loss-producing event immediately precedes the consequence. This is where the contact with a hazard

(unsafe act/condition, source of energy or substance) takes place. It is important to realise that there is the potential for an

undesirable consequence to occur and this will be dependent on the energies involved.

The term potential loss producing event is used in this block because, at this point, the contact with energy or substance may

or may not be above the resistive limitation of the body, structure or environmental media that is exposed to this contact. If

the energy exchange is below the resistive limit of the body media or structure exposed, the incident sequence stops, i.e. no

harm, damage or injury occurs and the event results in a near-miss. If the resistive limit is exceeded, harm takes place and the

consequence is an accident. It is important to define the contact to assist one to understand the type of event that takes place.

Contacts can be classified into the following underlying types:

Caught between - in gears, belt rollers, rotating parts, drive bolts, chains, vehicles and trailers etc

Caught in - confined spaces, gears, pinch points, rollers, etc

Caught on - projecting or protruding objects, moving parts, etc

Caught under - object, material, equipment, plant, machinery, etc

Contact with - hot and cold surfaces, objects, materials or substances, toxic substances, energy sources, electrical sources,

chemicals, etc

Exposure to - toxic fumes, vapours, gasses, mists, extreme temperatures, ergonomic hazard, radioactive substance, noise,

chemical emission, etc

Fall from elevation to lower level - fall from ladder, platform, roof, stairs, scaffolding, structures, equipment, etc

Fall on same level - slip, trip, fall, etc

Handling - incorrect stacking, placing, storing, etc

Inundation - enter into water of unknown depth (drowning) or material in silos etc

Overstress - physical injury due to improper lifting, pushing, pulling, twisting, etc

Struck against - protruding objects, structures , etc

Struck by - mobile objects, vehicles, loads, etc


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THE DIRECT CAUSE OF INJURY

Whenever an injury occurs, a harmful level of energy is transferred to our body. We should describe the nature of that energy

transfer and refer to it as the direct cause of the injury.

Here are various forms of energy that could be harmful:

1. Acoustic energy - Excessive noise and vibration.

2. Chemical energy - Corrosive, toxic, flammable, or reactive substances. Involves a release of energy, ranging from "notviolent" to "explosive" and "capable of detonation".

3. Electrical energy - Low voltage and high voltage often described as contact with.

4. Kinetic (Impact) energy - Energy from "things in motion" and "impact," and are associated with the collision of objects in

relative motion to each other. It includes impact between moving objects, moving object against a stationary object, falling

objects, flying objects, and flying particles. Also involves movement resulting from hazards of high-pressure pneumatic or

hydraulic systems. This type of event is often described as Struck by.

5. Mechanical energy - Cut, crush, bend, shear, pinch, wrap, pull, and puncture. Such hazards are associated with components

that move in circular, transverse (single direction), or reciprocating motion.

6. Potential (Stored) energy - Involves "stored energy." Includes objects that are under pressure, tension, or compression; or

objects that attract or repulse one another. Susceptible to sudden unexpected movement. Includes gravity - potentialfalling objects, potential falls of persons. Includes forces transferred biomechanically to the human body during lifting.

7. Radiant energy hazards - Relatively short wavelength energy forms within the electromagnetic spectrum. Includes infra-red,

microwave, ultra-violet, x-ray, and ionizing radiation.

8. Thermal energy - Excessive heat, extreme cold, sources of flame ignition, flame propagation, and heat related explosions.

LET'S TAKE A LOOK AT SOME EXAMPLES DESCRIBING THE DIRECT CAUSE OF INJURY:

If a harsh acid splashes on our face, we may suffer a chemical burn because our skin has been exposed to a chemical form of

energy that destroys tissue.

In this instance, the direct cause of the injury is harmful due to a chemical reaction. The related immediate cause might be the

person working without face protection (unsafe behaviour).

If our workload is too strenuous, force requirements on our body may cause a muscle strain. Here, the direct cause of injury is

a harmful level of kinetic energy (energy resulting from motion), causing injury to muscle tissue.

If a person working at height (hazardous activity) trips and falls from height (event) and strikes the ground 8m below and dies

as a result of internal injuries sustained, the direct cause of the injury can be described as a result of fall from higher to lowerlevel the ground. The kinetic energy involved is due to the effects of gravity and exceeds to limitations of the body to absorb

the energy on impact.


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SECTION TEN: IDENTIFY THE ABSENT OR FAILEDDEFENCES

These failures result from inadequate or absent defences that failed to detect and protect the system against technical and

human failures. These are the last minute measures, which did not prevent the outcome or mitigate the consequences of an

individual or team action that resulted in an incident or near miss.

The categories represent successive lines of defence where each defensive layer comes into operation on the failure of its

predecessor.

Defences in incident investigation:

Awareness To understand the nature and severity of the hazardous conditions present at the

worksite. Awareness problems reflect continuous shortcomings in those involved on-site

or those supervising and managing processes.

Detection To provide clear warning of both the presence and the nature of a potentially hazardous

situation.

Control and

Interim Recovery

To restore people or equipment to a safe state with minimal injury or damage.

Protection and

Containment

To limit the adverse consequences of any unplanned release of mass, energy or hazardous

material.

Escape and Rescue To evacuate all potential victims from the hazard location as quickly and safely as possible.

The above model reflects the failed defences in the deep-water horizon (Macondo) incident.


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SECTION ELEVEN: IDENTIFY THE INDIVIDUAL / TEAMACTIONS

These are the errors or violations that immediately precede the incident. They are typically associated with personnel having

direct contact with the equipment, such as operators or maintenance personnel. They are always committed actively

(someone did or didnt do something i.e. they acted unsafely or failed to act i.e. an omission) and have a direct relation to the

incident.

For most of the time however, the defences built into our operations prevent these human errors from causing harm.

Once again keep asking why? someone acted (or was allowed to act) in the way they did or didnt act the way they should

have leading up to the incident.

HUMAN FAILURE:

There are two main types of human failure:

1. Human error is an unintentional action or decision.2. Violations are intentional failures deliberately doing the wrong thing.

HUMAN ERROR

There are three types of human error: (skill-based errors)

1. slips2. lapses3. mistakes

These types of human error can happen to even the most experienced and well-trained person.

SLIPS AND LAPSES

Slips and lapses occur in very familiar tasks, which we can carry out without much conscious attention, e.g. using a grinder.

These tasks are very vulnerable to slips and lapses when our attention is diverted even for a moment.

SL I P S

Refers to errors in which the right intention or plan is incorrectly executed. Usually occur during well-practiced and familiar

tasks in which our actions are largely automatic.

Examples of slips include:

performing an action too soon in a procedure, or leaving it too late, e.g. not putting your safety glasses or ear muffson before starting the machine;

omitting a step or series of steps from a task, e.g. forgetting to connect the lanyard while refuelling the aircraft; carrying out an action with too much or too little strength, e.g. over-torqueing a bolt on a flange; performing an action in the wrong direction, e.g. a MEWP operator pushing the joystick to the left instead of the

right;

doing the right thing but on the wrong object, e.g. selecting the wrong size wrench for the job; and carrying out the wrong check but on the right item, e.g. checking a pressure gauge but for the wrong value.

LA P SES

Refers to failures to carry out an action. Largely involve failures of memory.

Forgetting to do something, or losing your place midway through a task.

Examples of lapses include:

forgetting to tighten a scaffold transom; taking your safety glasses off to see properly and then forgetting to put them back on; failing to secure scaffolding because of an interruption; and forgetting to install an earth rod before operating a generator.

Slips and lapses occur when:

people confuse two similar tasks; steps in a procedure dont follow naturally;


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tasks are too complicated and lengthy; the main activity is completed but the finer details are missed; the task is very familiar and requires little thought; there are too many distractions and interruptions.

M I STA K E S

Mistakes are decision-making failures. The two main types of mistake are rule-based mistakes and knowledge-based mistakes.

They arise when we do the wrong thing, believing it to be right. Typically they involve deficiencies or failures in the judgement

process. More subtle, more complex and less well understood than slips and lapses and harder to detect.

Examples of mistakes include:

making a poor judgement when overtaking, leaving insufficient room to complete the manoeuvre in the face ofoncoming traffic; and

an operator misinterpreting the sound of a machine breakdown and failing to switch it off immediately.Why do mistakes occur?

doing too many things at the same time. doing too many complex tasks at once. time pressures.

Factors which contribute to people making mistakes

the work environment eg too hot, too cold, poor lighting, restricted workspace, noise. extreme task demands eg high workloads, boring and repetitive jobs, jobs that require a lot of concentration, too

many distractions.

social issues eg peer pressure, conflicting attitudes to health and safety, conflicting attitudes of workers on how tocomplete work, too few workers.

individual stressors eg drugs and alcohol, lack of sleep, family problems, ill health. equipment problems eg inaccurate or confusing instructions and procedures. organisational issues eg failing to understand where mistakes can occur and implement controls, such as training

and monitoring.

How you can reduce mistakes? To avoid rule-based mistakes, increase worker situational awareness of high-risk tasks on site and provide procedures

for predictable non-routine, high-risk tasks.

To avoid knowledge-based mistakes, ensure proper supervision for inexperienced workers and provide job aids anddiagrams to explain procedures.

VIOLATIONS

These are intentional failuresdeliberately doing the wrong thing. The violation of health and safety rules or procedures is

one of the biggest causes of accidents and injuries at work. Workplace rules are broken for many different reasons:

I felt I had no choice (intentional due to the situation or rules). I wasnt particularly concerned about the consequences (intentional violations).

Deliberate deviation from safe operating practices, procedures, standards or rules.

ROUTINE (corner cutting/ implicitly accepted).

EXCEPTIONAL (unusual circumstances).

DELIBERATE ACTS of SABOTAGE (damage intent).

Examples of violations include:

scaffolders not clipping on their harnesses above 2 m; plant drivers not wearing seat belts; plant operators not carrying out pre-use safety checks; a site manager allowing untrained drivers to operate plant; a tradesman starting work on a new site without reporting to the site manager or receiving a site induction; and a worker thinking a rule is unsafe and taking off their safety goggles to improve visibility.


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Typical causes of violations include:

a lack of understanding of why the rule is in place; being under time pressure; not having enough workers to do the work; not having the right equipment; peer pressure; perception that they wont get caught; perceptions that rules are too strict or unnecessary i.e. the perceived benefits outweigh the perceived penalties; wanting to take the easy option; workers thinking rules dont apply to them;

How you can reduce violations

Always think about the possibility of violations when carrying out risk assessments. Ask the workforce to get involved in changes to rules to increase their acceptance. Assess the use of personal protective clothes and equipment (PPE). Have workers got the right equipment to do the

job? Is the PPE difficult to use or uncomfortable?

Encourage the reporting of any problems (such as job pressures) through open communication. Explain to workers the reasons behind any rules and procedures and their relevance. Improve planning for all jobs to ensure the necessary resources (workers, equipment, and time) are allocated. Improve the working environment. Is the environment unpleasant (e.g. dust, fumes, extreme heat or cold)? Have

workers got enough space to work in without discomfort or difficulty completing the task?

Make sure rules and procedures are relevant and practical. Are procedures hard to read or out of date?. Provide training for abnormal and emergency situations. Provide workers with appropriate supervision. Try to reduce time pressures on workers to act quickly in unusual situations. You can increase the chances of spotting violations by increasing routine monitoring.

The following diagram shows the various categories used to classify human error, which are initially split into intended orunintended actions.


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SECTION THIRTEEN:IDENTIFY THE TASK / ENVIRONMENTAL

FACTORS (UNDERLYING CAUSES)

These are the organisational factors or conditions in the work place in existence immediately prior to or at the time of the

incident. These are the conditions that directly influence human and equipment performance in the workplace. These are the

circumstances under which the errors and violations took place and can be embedded in task demands, the work

environment, individual capabilities and human factors.

The Task/ Environmental Factors can be categorised in two groups: Human Factors and Workplace Factors. Within the twogroups, we can categorise factors which encourage the commission of errors. The factors that can produce violations and the

common factors which may promote errors and/ or violations.

HUMAN FAC TO RS

Error Factors Common Factors Violation Factors

Preoccupation, distraction Insufficient ability Age and gender

Memory failure Inadequate skill High-risk target

Strong motor programmes Skill overcomes danger Behaviour beliefs

Perceptual set Unfamiliarity with task Subjective norms condoning violations

False sensations Poor judgement: illusion of control or least effort Personality: unstable extrovert, non-compliant

False perceptions Over confidence Perceived behavioural control

Confirmation bias Performance anxiety Low morale

Situational awareness Time pressures Bad mood

Incomplete knowledge Arousal state: monotony and boredom, emotional status Job dissatisfaction

Inaccurate knowledge Attitude to the system

Inference and reasoning Misperception of hazards

Stress and fatigue Low self-esteem

Disturbed sleep patterns Learned helplessness

Error proneness

WO R K P L A C E FA C T O R S

Error Factors Common Factors Violation Factors

Change of routine Time shortage Violations tolerated

Negative transfer Inadequate tools and equipment Compliance goes unrewarded

Poor signal/ noise ratio Poor procedures and instructions Procedures protect the system not the individual

Designer/ user mismatch Inadequate training Macho culture

Educational mismatch Hazards not identified Perceived license to bend rules

Hostile environment Under manning Adversarial industrial climate

Domestic problem Inadequate supervision Low operator pay

Poor communications Poor access to job Low operator status

Poor mix of hands-on work and written

instruction (reliance on undocumented

knowledge)

Poor housekeeping Unfair management sanctions

Poor shift patterns/ overtime working Poor supervisor/ worker ratio Blame culture

Poor working conditions Poor supervisory example

Inadequate mix of experience/ inexperienced workers Task allows for easy short-cuts


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UN D E R L Y I N G C A U SES : H U M A N A N D WO R K P L A CE FA CTO R S

Underlying (root) causes are the deeper basic causes, which initiate the immediate causes. In order to determine the

underlying cause one must consider the evidence and ask how does this evidence support the underlying cause? i.e. is there

a direct relationship between the underlying cause element and the evidence. For example, the evidence confirms that the

supervisor failed to comply with the procedure due to mental stress. The question that needs to be asked is whether this

evidence (a critical factor) has got anything to do with 3. Mental state. The answer would be affirmative. Thereafter one needs

to determine which sub element applies.

The underlying causes are classified under two main headings, namely Human Factors and Work Place Factors.

HUMAN F ACTORS A R E T H O S E F A C T O R S , W H I CH A R E D I R ECTL Y A SSO CI A TED W I TH TH E P E R SO N(S)

They support the reason why a person acted the way he/she did. The following case study may illustrate the meaning of

Human factors and Work Place factors:

An electrician attempted to isolate a high voltage switch and failed to lock out and earth correctly. He contacted 11 kva and

was badly burnt. One substandard practice would be failing to lock out. If queried as to why the person failed to lock out it

might come to light that he had not been trained and hence had no experience of the lock out procedure and the process of

locking out. This would mean lack of knowledge or experience is the Human factor. Inadequate training would be the Work

Place factor.

W ORK PL ACE F ACTORS A R E TH O SE F A CTO R S W H I CH A R E D I R ECTL Y A SSO CI A TED W I TH TH E O R GA N I SA TI O N A L

P R O CE SSES

In the scenario presented, it is very likely that there are other Work Place factors which may support the persons practices

such as inadequate training, inspections, audits, reviews, communication, supervision, engineering standards, procurement,

tools or equipment etc.


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SECTION FOURTEEN:MANAGEMENT CONTROL

INADEQUATE SYSTEMS CONTROL ORGANISATIONAL FACTORS

Identify the Organisational Factors: These are the underlying organisational factors that produce the conditions which affect

performance in the workplace. They may lie dormant or undetected for a long time within an organisation and the

repercussions may only become apparent when they combine with the local conditions or errors or violations to breach the

systems defences. These may include fallible management decisions, processes and practices.

ICAM classifies the system failures into Organisational Factor Types (OFTs) as follows:

Organisational Factor Types (OFTs)

CO Communication

CM Contractor Management

DE Design

HW Hardware

IG Incompatible Goal

MM Maintenance Management

MC Management of Change

OR Organisation

PR Procedures

RM Risk Management

TR Training

Sub-standard acts and conditions are preceded by underlying causes, however, they do not initiate the incident causation

cycle. The underlying causes manifest themselves due to the management controls being inadequate. These controls relate to

the safety management system and risk management enablers such as leadership, policy and strategy, people, resources,

governance, risk management process, compliance, supervision, inspections, maintenance, purchasing, contractor

management, planning, scheduling, reviews, instructions, investigations, corrective practices, communications, etc.

Effective management control is when all processes and procedures, established to ensure the organisation fulfils its

obligations are complied with. In order for the HSE system to be effective, a number of important criteria need to be met:

i. The safety management system must be well developed and thoroughly implementedii. Roles, responsibilities and authority must be assigned and acceptediii. Policies, rules, regulations and standards need to be well established and understoodiv. Compliance with the requirements must be adequatev. There must be suitable systems of workvi. Key competencies must be deployed


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ROLES , RESPONSIBILITIES AND AUTHORITIES DEFINE:

the work necessary to meet the organisations objectives who is responsible for the work to be performed who is accountable for what what specific actions are necessary the frequency with which these actions are to be taken who reports what to who, when

SAFETY MANAGEMENT SYSTEM

The effectiveness of any safety management system is dependent on the systems design criteria. The design and

implementation of an organisations safety management system is influenced by:

i. Complexity of organisational activities;ii. Established targets and objectives;iii. Legislative, statutory, regulatory and other requirements;iv. Organisational needs;v. Organisations risk profile;vi. Processes and operations;vii. Products manufactured and services provided; andviii. Size, structure and location of the organisation.

The system should typically be structured to accommodate the elements below:

COMMON MANAGEMENT SYSTEM FRAMEWORK HSE MANAGEMENT ELEMENTS:

LEADERSHIP AND ACCOUNTABILITY

RISK MANAGEMENT

SKILLS, TRAINING AND BEHAVIOURS (COMPETENCE)

ASSET INTEGRITY

BUSINESS CONTINUITY MANAGEMENT

COMMUNITY AND STAKEHOLDERS AWARENESS

CONTRACTORS AND SERVICE PROVIDERS

CORRECTIVE AND PREVENTIVE ACTION SYSTEMS

CORPORATE COMMUNICATIONS

CRISIS AND EMERGENCY RESPONSE MANAGEMENT

CUSTOMERS AND PRODUCTS

ENVIRONMENTAL MANAGEMENT

FACILITIES DESIGN AND CONSTRUCTION

INCIDENT MANAGEMENT

INFORMATION AND DATA MANAGEMENT

MANAGEMENT OF CHANGE

OCCUPATIONAL HEALTH

OPERATIONS AND MAINTENANCE

RECORDS AND DOCUMENTATION

ASSESSMENT, ASSURANCE AND IMPROVEMENT

CORE PDO HSE MANAGEMENT SYSTEM CP122 ELEMENTS

LEADERSHIP AND COMMITMENT POLICY AND STRATEGIC OBJECTIVE ORGANIZATION, REPSONSIBILITES, RESOURCES, STANDARDS, AND DOCUMENTS HAZARDS AND EFFECTS MANAGEMENT PLANNING AND PROCEDURES IMPLEMENTATION AND OPERATION ASSURANCE MONITORING AND AUDIT REVIEW


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SECTION FIFTEEN: RISK ASSESSMENTS

INADEQUATE RISK ASSESSMENT

Every organisation has to contend with risk in the work environment. OSHA states: The employer shall make an evaluation

of the risk attached to any condition or situation which may arise from the activities of such employer. This requires the

employer to conduct a risk assessment to quantify the extent of risk that has to be managed. This is the fundamental point

of departure for any safety management system. It involves understanding the exposures in the work place and

implementing control measures to safeguard against the risk. Hence the various elements of the safety management system

are the measures the organisation puts in place to safeguard its employees from the exposures. It is a process, which is

proactive.

The organisation should have a documented procedure established, implemented, and maintained for effective

identification of hazards, assessment of risks and implementation of appropriate management control processes to ensure

that risks are reduced to an acceptable level.

Furthermore they should consider all legal, statutory, regulatory and other requirements that the organisation is subjected

to.

Policies, plans and actions need to be developed

Targets and objectives need to be set against the background of the risk assessment and suitable action plans and programs

need to be assigned.


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APPENDIX A COMMUNICATION

Failure to communicate when the target is known but the message fails to get through or is late. Involves inadequate

hardware and miscomprehension by those involved. Failure to validate understanding

Inadequate Communication can be caused by:

Inability to make contact with the correct person.Lack of clear line of communication.

Language problems and cultural barriers.

Missing or excessive information.

No standard communication format.

Poor feedback.

Unreceptive or hostile target.

Inadequate Communication can lead to:

Missing information, people not informed, do not report.

Misunderstanding or incorrect interpretation.

Not knowing where information is located.

People not knowing who to inform.

Taking inappropriate action at the wrong time or place

CONTRACTOR MANAGEMENT

The evaluation, selection and retention of contracted services, equipment, personnel and material to ensure risks to people,

the environment, equipment or property are reduced to a level which is ARLAP.

Inadequate Contractor Management can be caused by:

Contract not clearly defining HSE obligations, performance and reporting requirements.

Inadequate or poorly conducted contract management process.

Inadequate or poorly conducted HSE compliance and performance monitoring and review.

Lack of clearly defined work scope.

Lack of consideration of risk associated with the contract.

Lack of formal contractor evaluation procedure.

Poorly defined selection criteria giving undue weight to cost over performance.

The failure to identify/ plan bridging requirements between the contractor and many standards.

Unclear reporting relationships, lines of communication, roles and responsibilities.

Inadequate Contractor Management can lead to:

Deferring, conflicting, or poor interface of procedures and systems of work.

Deterioration in production and safety performance.

Imbalance between contract compliance, production and HSE goals.

Lack of reporting of hazards, near misses and incidents.

Poor employee / contractor relations, industrial relations issues, high personnel turnover.

Requirement for additional supervision.

Risk levels above ALARP.Substandard competency and staffing levels.


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DESIGN

The way in which equipment is constructed to make certain operations difficult or allow unexpected usage. Poor design may

require extra effort and unusual maintenance. Inadequate design capacity may lead to extending the equipment beyond

limits. Many design failures result from the physical and professional separation of the designer and end user.

Inadequate Design can be caused by:

No standardisation of equipment or usage.

No adapting to human needs and limitations.

Poor designer-user communication.

Time or financial constraints.

No indication of system status provided by design (on/ off, working or not, etc.).

Inadequate design premise data.

Inadequate Design can lead to:

Extra effort to do the job.

Unexpected performance of tools and equipment.

Inability to operate equipment properly.

Inability/ difficulty in controlling processes.

Long or repeated training requirements.

Equipment is unused or improvised usage.

HARDWARE

The quality, availability and position in life-cycle of tools, equipment and components. Its concerned with t he materials

selected rather than design or poor maintenance of the equipment.

Inadequate Hardware can be caused by:

Poor stock or ordering system.

Poor quality due to the local availability.

Poor state of existing equipment.

Inadequate maintenance

Equipment not fit for purpose.

Lack of resources available to buy, maintain or improve equipment.

Theft.

Inadequate Hardware can lead to:

Inappropriate use of tools or equipment.

Absence or unavailability of tools or equipment.

Improvisation, i.e. using tools unsuitable for the job.


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TRAINING

The provision and imparting of the correct knowledge and skills to employees which are necessary for them to do their job

safely. Failure may involve insufficient or too much training, lack of resources or assessment and mismatch of abilities to tasks.

Inadequate Training can be caused by:

Differing standards of training.

Ineffective pre-employment selection process.Lack of appreciation of benefits

Making assumptions about a persons knowledge or skills.

No assessment of training effectiveness.

Poor planning of when training is needed.

Training not directed to all the job skill requirements.

Training the wrong people.

Inadequate Training can lead to:

Employees unable to perform their jobs.

Excessive supervision.

Excessive time spent in training.

Increased numbers of people required for the job.

Job taking longer, of poor quality, wasting material.

ORGANISATION

Deficiencies in the structure of the organisation, lack of defined responsibility and inappropriate authority to current work.

May involve co-ordination, supervision of communication and feedback.

Inadequate Organisation can be caused by:

Excessive bureaucracy.

Frequent reorganisations.

Lack of definition of objectives.

No structure to co-ordinate different activities.

Poor planning.

Poorly defined departments or sections.

Unclear roles, accountability, authority, responsibility or delegation.

Inadequate Organisation can lead to:

Multi-layer hierarchy, slow response to changes.

Wrong person, or nobody, takes responsibility.

Resources used for non-business needs.

Decisions delayed or deferred.

People are only held responsible, not accountable for their actions/ decisions.

Poor control or management of events.

Rules and procedures not enforced.


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INCOMPATIBLE GOAL

The presence of conflicts between production, safety, planning and economic goals as well as conflicts between group and

peer pressures and personal goals. Incompatible goals become a problem when senior management provide no guidelines on

priorities

Incompatible Goal can be caused by:

Conflict between appearance and functionality in a design.

Conflict between safe work and production priorities.

Conflict between work and personal priorities.

Imbalance between safety requirements and budget constraints.

Taking procedural short-cuts for personal / production gain.

Incompatible Goal can lead to:

Operating closer than normal to operating limits.

Overruling or relaxing procedures.

Putting people under pressure.

Short-cutting a procedure.

Suppressing information about hazards or injuries.

PROCEDURES

The presence of accurate, understandable procedures which are known and used. Relates to the way in which procedures are

written, tested and documented and controlled.

Inadequate Procedures can be caused by:

Poor knowledge of the procedure writer.

Poor feedback on practicality.

Poor indexing or retrieval methods.

Gaps in the inventory of procedures needed.

Non-operational objectives (political/ organisational).

Failure to have revision control system.

Inadequate Procedures can lead to:

Ambiguous, non- comprehensive, incorrect or outdated documents.Difficult access for the users.

No procedures for some specific tasks.

Too many, overlapping or conflicting procedures.

Failure to communicate existing or new procedures.

Documents in the wrong language.

Difficult procedures which encourage short-cuts

Toleration of violations


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MAINTENANCE MANAGEMENT

The appropriateness of the management of the maintenance system, involving planning, resourcing and type of maintenance

rather than the execution of maintenance jobs. Poor practices, involving procedures, tools and training, are covered

elsewhere.

Inadequate Maintenance Management can be caused by

Absent/ inadequate manuals and documents.

Incorrect maintenance strategy.

Poor planning, controlling, execution and recording of maintenance.

Shortage of specialised maintenance personnel.

State of equipment not communicated to relevant people.

Inadequate Maintenance Management can lead to:

Breakdown before life expectancy.

Defective or malfunctioning equipment.

Equipment not operable in the way intended.

Makeshift or unplanned maintenance.

Unexpected rapid corrosion.

RISK MANAGEMENT

The systematic application of management policies, processes and procedures to the tasks of identifying, analysing, assessing,

reducing to ALARP (As Low as Reasonably Practical), and on-going monitoring of risk in man-machine systems that contain a

potential to have an adverse effect on people, the environment, equipment, property or the community

Inadequate Risk Management can be caused by:

Goals, objectives, scope and boundaries of risk management activity not clearly determined

Hazard identification process not being systematic, or covering all operations and equipment.

Inadequate monitoring of risk control effectiveness.

Inadequate or poorly conducted risk management process.

Inappropriate selection or poor implementation of risk measures.

Level of risk analysis (JSA, QRA, HSE Safety Case, etc.) inappropriate for the degree of risk or phase of lifecycle.

Risk assessment conducted without the appropriate competencies and experience

Inadequate Risk Management can lead to:Risk levels above ALARP

Uncontrolled hazards and consequences

High incident and accident rate

Inappropriate risk ranking and allocation of risk control resources

Incomplete, inadequate, or out of date Risk Register

Breach of local regulatory requirements


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MANAGEMENT OF CHANGE

The systematic assessment of change to operations, processes, equipment, services and personnel for potential risk and the

application of appropriate action to ensure existing performance levels are not compromised

Inadequate Management of Change can be caused by:

Inadequate monitoring of the effects of change to existing performance levels.Inadequate or poorly conducted management of change process.

Inadequate risk vs. benefit assessment of the impact of change.

Inadequate tollgate mechanism to approve proposed change.

Objectives and scope of change activity not clearly determined.

Poor change implementation plan.

Poor communication of change

Inadequate Management of Change can lead to:

Adverse impact on production and safety performance.

Breach of local regulatory requirements.

Increase in equipment breakdown or damage.

Insufficient manning levels, confusion and low morale.

Mismatch between equipment, operating procedures and training.

Mismatch between policy, procedures and practice.

Risk levels above ALARP.

Undefined organisational structures and responsibilities.

Unexpected near misses, incident and accidents


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References

Cooke, David L. (2003). Learning from incidents (PDF). Proceedings of the 21st International conference of the System

Dynamics Society. http://www.systemdynamics.org/

conferences/2003/proceed/PAPERS/201.pdf

Davies, John; Alastair Ross, Brendan Wallace and Linda Wright (August 2003).

Safety management: A qualitative systems approach. London: Taylor and Francis. ISBN 0415303710

http://ehstoday.com/news/ehs_imp_32824/

Mescon et al 1985

Parket Follett, 1941

Henri Fayol

Hersey and Blanchard

Warren Bennis and Dan Goldsmith

Paul Birch

Patricia Pitcher

Bruce Lynn Industrial Accident Prevention, H W Heinrich

Rockwell Automation, Proving the value of safety, Justification and ROI of safety programs and machine safety investments, Lyle

Masimore, Rockwell Automation.

The Compass: Management Practice Specialty News, Why Youve Been Handed Responsibility for Safety, J.J. Keller and

Associates, Winter 2000, pp. 1, 4.

Bird Frank E., Germain George L., Loss Control Management: Practical Loss Control Leadership, Revised Edition, Det Norske

Veritas (U.S.A.), Inc, Figure 1-3, pp. 5, 1996, Adapted for use. Written by Nigel Pitt for IMORSAhttp://www.imorsa.com/
http://literature.rockwellautomation.com/idc/groups/literature/documents/wp/safety-wp004_-en-p.pdfhttp://www.imorsa.com/http://www.imorsa.com/http://www.imorsa.com/http://www.imorsa.com/http://literature.rockwellautomation.com/idc/groups/literature/documents/wp/safety-wp004_-en-p.pdf

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