Causes and effects of accidents

The Risks and the Causes of Accidents

LinkedIn Group EHSQ Elite - 1 ©VOF LCCB 2014

The filtering tower supports and guides the analysis of undesired events and the construction of an adequate Loss Control System. In the new paradigm of Loss Control we built a Loss Control System from the inside out and we use the terms “Accident Analysis” rather than “Accident Investigation”. The aim of the game is ultimately to implement solutions derived form the identified causes and not to blame the culprits! In the new paradigm of Loss Control all members of the Community work towards this goal. Only by this way, point 8 of Edwards W. Demings’ program to survive the crisis – ‘Drive out Fear- will become reality. So one should use in the new paradigm of Loss Control only those analyze models that do NOT put the blame on either the workers OR management. The new paradigm needs models through which management AND workers accept together their responsibility to find the underlying real causes of the undesired events. In the new paradigm there will be a tremendous shift form “putting to blame” to “accepting from the inside out accountability”. Integrated Loss Control is aimed at the control of hazards, risks, undesired events and losses. Therefor integrated Loss Control deals in particular with the causes of those undesired events and the minimizing of their effects. Indeed, as a cause is found at the beginning of a realized loss, the risk is the origin of a not yet realized loss. The main difference between a risk and a cause is that the cause is an element of the past and the risk an element of the present and the future. Among the practical principles of professional Management is the Principle of Multiple Causes:

This is an essential principle for Loss Control Management. One should never assume that there is a single cause of an accident or incident. And W. G. Johnson author of MORT Safety Assurance Systems said that:

THE RISKS AND THE CAUSES

OF ACCIDENTS

1. Dynamic Causes and

Effects Model

“Problems and loss producing events are seldom, if ever, the result of a single cause”



Experience shows that a majority of accidents involve substandard practices, substandard condition and a substandard organization of the workplace. And these are only the symptoms. Behind the symptoms are the basic causes, the deficiencies in the Loss Control System, the personal, technical and organizational factors that led tot the substandard acts, conditions and organization of the workplace. It is good to keep in mind that, whilst we must try to identify every possible cause of a problem, we should give the greatest amount of attention to those with the greatest potential of loss severity and the greatest potential of recurrence, so the greatest risk! This is essential to effective Loss Control. These principles will become clear using LCCB’s cause and effect model. This Model is useful to find the different causes of an undesired event. One should keep in mind that it is a model and not the reality. A model is always a representation of the reality and is needed in order to appreciatively understand the reality and for deep communication with other (which is needed for proper motivation for Loss Control).

“Undesired event will be caused by many causes linked in a causal or temporal

sequence”.

Figure 1



In the following pages we will briefly describe the different components of the model. Tough the model can be used in both directions (top-down and bottom-up), thus proactive and active, we have chosen for the pro-active presentation because experience as taught us that this is the best way. The following question can be the problem definition: How are hazards transformed in losses? Or what is the sequence of the risks (facts) that causes this transformation to happen? The filtering tower gives a dynamic answer to those questions! The metaphor we use for the Organization is a tower is placed in the middle of an Archipelago of dangers and risks. One can indeed see those dangers and risks as an archipelago of icebergs that threaten the Organization. The Organization has to protect herself against hose dangers and risks. A lot of those are energies or products that causes losses whenever there is a direct contact with a body or a structure. The dangers are essential components of a situation or a technical system. The dangers and risks that threaten the organization are countless. A very short list, by way of example:

Raw materials and products (toxic products, combustibles, explosives, radioactive components, …)

Engergies (electricity, steam, thermal fluids, pressure vessels, kinetic energy, …)

Social/Human dangers (strikes, absenteeism, vandalism, alcoholism, theft, …)

Financial dangers (non payment of invoices, market fluctuation, stock exchange fluctuation, price changes, …)

The definitions we use are:

The Organization has the responsibility to verify that the arrangement taken by the concerned parties (suppliers) have really diminished the risk at the acceptable level. If this is not the case supplementary action has to be taken by the Organization to lower the Risk under the acceptance level.

Danger and Risk Archipelago

A Risk is the probability of (accidental) loss and it is what rest of the Hazard after arrangements has been taken.

Hazard A Hazard is a situation or a system that has the potential to cause losses.

Risk



So the hazards and risks have to be treated adequately by the Organization before they enter the Organization. The tower or sometimes called ‘barrel’ is as been said a metaphor for the Organization. This treatment of the hazards and risks is done by the Management Loss Control System or shortly Management System, since the control system is a Management responsibility. The system functions as a filter or sieve. The quality and the functioning of this sieve are in fact responsible for the diking in of those hazards and risk. The control system has three subsystems that are closely interconnected (figure 3):

Man: Personal Factors,

Technique: Technical Job Factors

Organizational: Organizational Job Factors

Figure 2

Figure 3



The Personal Factors are Human factors of workers, staff personnel and managers. The Technical Job Factors are linked to the hardware aspects of the Organization and finally the organizational focus on the organizational aspects of the Organization.

Personal Factors Capability (Physical, Physiological, Mental and Psychological) Stress (Physical, Physiological, Mental and Psychological) Knowledge Skill Motivation

Technical Factors Engineering Purchasing Maintenance Inspection Tools and Equipment Excessive Wear and Tear Technical Hazard Analyze Process

Organizational Factors Leadership Safety System Contract Review Document Control Procedures/Instructions/Standards Control of Undesired Events Human Resources Management Accident Analysis System Technical Information System If the Organization had the knowledge of all hazards and risks and had the possibility to create an ideal Loss Control System, it would weave a sieve with a quality wire and a constant mesh. The dimension of the mesh would match the size of the acceptable risks. In reality this ideal situation is not possible since the Organization does not know all hazards and risks. Therefor it is possible that non-identified risks enter the organization (figure 4).



The first sieve is a metaphor for as well the theoretical Loss Control System as the functioning of that system at the management level. As been said, this system is not perfect, on one hand, some of the meshes are stretched out; on the other hand, there are some holes in the system! The size of the mesh reflects the quality of the Loss Control System and has of course to do with the exact place of the iso-criticality curve on the ‘pool of risks’. (Cf. Chapter 3 Risks). Stretched out meshes mean that management does not carefully for its own Loss Control System. Through the holes of the first net not filtered dangers en risks enter the Organization. This means that these are omissions and/or due to lack of knowledge at the management level. In the space under the first sieve or net one finds as well the accepted risks as the non-identified ones! Both are the responsibility of management. Those risks will ultimately become the direct causes. They are directly responsible for undesired events to happen. A second sieve should capture those risks. This sieve describes the quality of the treatment of those risks by the “reality of the workplace”. That reality consists of the behavior of the workers and their foreman, the physical conditions of the workplace and the quality of the coach procedures and instructions. Those three dimensions are strongly interconnected. In case of not correct functioning of this sieve one speaks of substandard actions, substandard conditions and a substandard organization of the workplace. In case an accident happens although the sieve is correct functioning this means that the accepted risks are transformed into undesired events.

Figuur 4

Accepted and Non-identified Risks



By this we mean to say that there exist a right (standard) way of doing things, right (standard) physical conditions and a right (standard) organization of the workplace, so that the work can be done without problems or undesired events – other than the ‘accepted’ ones. Traditionally the substandard behavior identified was the behavior of those who where directly involved in the coming into being of the undesired event. This was - in case of an injury - most of the times the victim. Nowadays those substandard actions are linked to the substandard actions of other persons earlier in the sequence, for example, those who have created the substandard condition who is at the origin of the substandard behavior. How the second net looks like is given in figure 5.

We are using the following checklist: SUBSTANDARD ACTS 1. OPERATINGEQUIPMENT WITHOUT AUTHORITY 2. FAILURE TO WARN 3. FAILURE TO SECURE 4. OPERATING AT IMPROPER SPEED 5. MAKING SAFETY DEVICES INOPERATIVE 6. USING DEFECTIVE EQUIPMENT 7. USING (SAFE) EQUIPMENT IMPROPERLY 8. FAILING TO USE PPE PROPERLY 9. IMPROPER LOADING AND PLACEMENT 10. IMPROPER LIFTING

Figuur 5



11. IMPROPER POSITION FOR TASK 12. SERVICING EQUIPMENT IN OPERATION 13. NOT RECOGNIZING OR IMPROPER ASSESSMENT

OF A RISK 14. HORSEPLAY 15. UNDER INFLUENCE OF ALCOHOL AND/OR OTHER

DRUGS SUBSTANDARD TECHNICAL CONDITIONS 16. INADEQUATE GUARDS OR BARRIERS 17. INADEQUATE OR IMPROPER PERSONAL

PROTECTIVE EQUIPMENT 18. INADEQUATE OR IMPROPER COLLECTIVE

PROTECTIVE EQUIPMENT 19. DEFECTIVE TOOLS, EQUIPMENT OR MATERIALS 20. INADEQUATE ERGONOMIC ASPECTS OF THE

WORKPLACE (lay-out) 21. INADEQUATE WARNING SYSTEM 22. POOR HOUSEKEEPING DISORDER (piles of

materials, housekeeping,...) 23. USED MATERIALS (chemicals) 24. FIRE AND EXPLOSION HAZARDS 25. NOISE EXPOSURE 26. RADIATION EXPOSURE 27. TEMPERATURE, MOISTURE EXTREMES 28. INADEQUATE OR EXCESS ILLUMINATION 29. INADEQUATE VENTILATION 30. HAZARDOUS ENVIRONMENTAL CONDITIONS

(gasses, fumes, dust, smoke, ...) SUBSTANDARD ORGANIZATION OF THE WORKPLACE 31. LACK OF REFERENCE MANUAL ON THE

WORKPLACE 32. INCOMPLETE PROCEDURES, INSTRUCTIONS,

STANDARDS (P.I.S.) 33. INCORRECT P.I.S. (contradictions, inadequate

sequence of steps,...) 34. LACK OF CORRECT RULES AND REGULATIONS 35. LACK OF VISIBLE PRESENCE OF SUPERVISION 36. SUBSTANDARD CONTROL OF WORKPLACE

(measurement, evaluation and support of P.I.S.) 37. PLANNED INSPECTIONS NOT EXECUTED

ACCORDING STANDARDS 39. TASK ANALYSIS AND PROCEDURES NOT

EXECUTED ACCORDING STANDARDS 40. ACCIDENT/INCIDENT ANALYSIS NOT EXECUTED

ACCORDING STANDARDS 41. IMPROPER CONTROL OF COMPLIANCE OF

AGREEMENTS 42. LACK OF MOTIVATION/COACHING BY

MANAGEMENT



43. PERSONAL PROTECTIVE EQUIPMENT NOT AVAILABLE

44. COLLECTIVE PROTECTIVE EQUIPMENT NOT AVAILABLE

45. CORRECT EQUIPMENT NOT AVAILABLE Those three are interconnected. A substandard behavior, dismounting the machine protection cover, can lead to another substandard behavior: working at a non-protected machine. The causes are even created at the level of the different sieves. The not adequately applying of the engineering standards can lead to substandard conditions, which can lead to substandard behaviors, which ultimately lead to undesired events and losses. In the old paradigm accident investigation mostly stopped at the direct causes. Once those were found and especially once a substandard behavior was discovered the cause was found. In other words the culprit was found and this was sufficient. And this person was often the victim and almost always a worker.

Our model teaches us that there is more and that the risks must be seen as symptoms of underlying causes (i.e. the not correct functioning of the first sieve or the Loss Control System at the Management Level). Therefor we call the direct causes symptoms. By this we stress that they are not the real causes. On the other hand the second sieve is not always functioning correctly either The machines are not always well protected; the personnel is sometimes fatigued and not alert and through habitation does not see the risks anymore; the work instructions are not updated in case of changes, etceteras.

Figure 6



This sieve has - like the first one - also problems with stretched meshes and holes. Therefor sometimes bigger risks are taken than the accepted ones At the level of the second sieve the mesh dimensions describe the quality of the treatment of the risks. In case of increasing of the mesh dimensions, the probability of the accident to happen increases and/or the severity of the consequences increases. The risks find more an opening in the sieve and this leads to the undesired event, the undesired contact. The probability of an undesired event with a certain consequence increases and thus the risk. A real hole in the second sieve is a metaphor for an omission or a lack of knowledge at the level of the workplace. The workers and their front line supervisors have done a mistake, have forgotten it or have never known it! Under the second sieve we find the undesired events, the contacts between an energy and a body or a structure. When the second sieve is taken accidents and incidents will happen! An undesired event is the mishap that causes the losses. It is possible that the losses are minimal, due to the specific circumstances, or even that there are no real losses. This is the case of the mishap of a forklift that gets of the right track and that misses a drum of extremely toxic chemical or just hits the door so softly that there is no damage. In those cases we call those undesired events near misses or pure incidents. This does not mean that those events are unimportant, not at all. Indeed, by correctly analyzing those near misses we can prevent future losses to happen! Those near misses are learning events. And by the way, in slightly other circumstances (higher speed of the forklift, other place of the drum, …) the event could have created losses, even big losses (if the drum was severely damaged).

Undesired Events

Figure 7



The undesired event is the event that precedes the losses – the contact that could or does case the harm or the damage. When risks of accidents are existing, the way is always open for a contact with a source of energy above the threshold limit of the body or the structure. This source of energy can be kinetic energy, electric energy, chemical energy, thermal energy, and etceteras. When the energy transfer in that particular contact is above the threshold limit of the body or structure, we call the undesired event an accident, if not, we call it a near miss or an incident. Here is a list of common types of energy transfers:

Struck against (running or bumping into)

Struck by (hit by moving object)

Caught in (pinch and nip points)

Fall to same or lower level (slip and fall, tip over)

Contact with (electricity, heat, cold, radiation, caustics, toxic, noise)

Overstress/overexertion/overload Those contacts are undesired events generate losses and even after the contact there are still possibilities to minimize those losses. These activities constitute the third sieve: This third sieve is as you know not the best in Loss Control although still very needed. In most cases an organization has a theoretical correct sieve (at the Management level) to treat the undesired events. This sieve consists of the reactive Loss Control activities, not of the proactive ones. The latter are found on the first and second sieve. This sieve too has three dimensions: a human, a technical and an organizational one.

Human aspects:

Reporting of accidents

Adequate reaction of people at the moment of the accident

Quality of the rescue operations and first aid

Adequate use of the equipment and resources

Adequate transportation of the injured

Human aspects of the medical treatment

Rehabilitation of the injured

Technical aspects:

Quality of the equipment and tools

Distance between the scene of the accident and the First Aid Room

Speed of the reaction

Technical quality of the medical treatment



Functioning of the technical safety devices in order to minimize losses

Repair and replacement of the damaged equipment and other property damage

Organizational aspects

Internal Communication Plan

External Communication Plan

Rescue Plan

Medical Service Plan

Procedure Restricted Work, adapted work

Insurance’s

And also this sieve is not perfect either and has stretched meshes and holes. Stretched meshes indicate for example the not adequate execution of tasks during emergencies (due to stress, pushing, …). A hole in the third sieves pictures an omission or a lack of knowledge concerning the treatment of the undesired event during the emergency (this as well by managers as by other personnel). Ultimately the undesired events, when they succeed in passing ‘successfully’ the last defense barrier, are transformed in real losses. As you can see in Figure 7 the filtering tower or barrel is closed at the bottom, this means that the losses have to be absorbed by the organization!

Figure 8



The results of an accident are losses. As reflected in our definition the most obvious ones are harm to people, property and process. The categories of losses are:

People Motivation/Morale Material/Property Damage Environment Image Market Management

People

Those people will be often own personnel and can also be neighbors, clients and contractor personnel.

Nothing is more important or more tragic than the human aspects of accidental loss:

Injuries (first aid and doctor cases)

Days away from Work injuries;

Loss of body parts or functions;

Fatalities;

Occupational illnesses;

Disability. Not only physical, but also the psychological injuries (pain, sorrow, anguish, …) are possible losses. In the new paradigm of Loss Control one will take more care of the latter, non-visible injuries than before.

Motivation/Morale

The diminishing of the motivation and the moral of the personnel due to too many undesired events is a loss that can lead to less production, less quality, more absenteeism, higher risk behavior, etc.

Material

Loss of material: raw materials, products, contamination of materials and end products, lower production quota,…

Property

Property damage, material cost of repair and replacement of parts, expenditures of equipment, …

Environment

Losses due to the accidental burdening of the environment.

Image

Loss of business an goodwill, adverse publicity, Legal suits and expenses, …

Market

Loss of orders, clients or market share due to loss of image or product damage or product liability.

Management

Loss due to the damage of the image of management. Loss of goodwill of management at all levels.

Losses



The Cause and Effect sequence visualizes top management’s responsibility regarding the control of the underlying causes of accidents. The need of management control is tremendous. Without it the accident sequence begins and triggers the continual causal factors that lead to loss. Without adequate management control, the accident cause and effect sequence is started and, unless corrected in time, leads to losses. In the quality paradigm, Deming and others, stated that 80 to 84% of the causes of quality problems were to due to the management control system. Accident Investigations of numerous disasters underline the tremendous responsibility and accountability of top management: The Herald of Free Enterprise, the Challenger, The King Cross Fire, Piper Alpha, Exxon Valdez, Heysel Drama, … Management has to create its Loss Control System and the standards of it. Management not only plans and organizes the work to be done to meet those standards, it also evaluates results and needs, commends and corrects performance. This is the essence of Management Control. This is visualized by the Deming cycle left to the filtering tower: PDCA!

This means too that management is responsible of continual improving of the Loss Control System by adding system activities and by specifying adapted standards or criteria. Adequate standards are essential for adequate control. Lack of compliance to those standards is a common reason for lack of control. Developing an adequate Loss Control System and standards is an executive function, aided by supervisors. Maintaining compliance with those standards is a supervisory function, aided by executives. It is a management effort all the way!

Management Responsibilities

Figure 9

Leadership & Management

Causes and effects of accidents