2. Learning Outcomes
At the end of this topic, students should be able to:
1. Explain causes of accident
2. List down all causes of accident
3. Explain the importance of incident investigation
4. Discuss on accident outcomes
3. Causes of Adverse Events
Adverse events have many causes
What may appear to be bad luck (being in the
wrong place at the wrong time) can, on analysis, be
seen as a chain of failures and errors that lead
almost inevitably to the adverse event
This is often known as the Domino effect
4. Causes of Adverse Events
These causes can be classified as:
immediate causes: the agent of injury or ill health
(the blade, the substance, the dust etc)
underlying causes: unsafe acts and unsafe conditions
(the guard removed, the ventilation switched off etc)
root causes: the failure from which all other failings
grow, often remote in time and space from the
adverse event (eg failure to identify training needs
and assess competence, low priority given to risk
assessment etc).
5. Causes of Adverse Events
To prevent adverse events, one need to provide
effective risk control measures which address the
immediate, underlying and root causes.
Sequence of
dominoes
6. Accident Causation – Unsafe Acts
Horseplay
Defeating safety devices
Failure to secure or warn
Operating without authority
Working on moving equipment
Taking an unsafe position or posture
7. Accident Causation – Unsafe Acts
Operating or working at an unsafe speed
Unsafe loading, placing, mixing, combining
Failure to use personal protective equipment.
15. Accident Outcomes
Direct outcomes such as injuries, fatalities and
losses to equipment and assets oversimplifies the
“result” of an accident
In addition to the injuries, fatalities, and loss and
damage of physical assets, there are a wide range
of additional outcomes associated with accidents
16. Accident Outcomes
An employee will suffer loss of confidence, and his
or her relationship with his or her colleagues and
supervisor will shift
If an injury has been sustained, then there may be
long-term workplace consequences
17. health
Economically, injury and ill
additional financial burdens on individuals
can place
and
families, at a time when these resources may already
be stretched
Changes in mobility, fitness or health resulting from
the accident will also influence life satisfaction and
well-being
Accident Outcomes
18. Behavioural and psychological changes resulting
from the accident may be of long-term consequence
The nature of family relationships and relationships
with friends may change for the organisation
Accident Outcomes
19. Additional negative outcomes include:
direct economic costs of loss of working time and
production
the loss of future contracts and possible threats to
the continuity of the business
increased insurance risks and premiums; and loss of
reputation and goodwill, all of which can be difficult
to quantify
Accident Outcomes
20. Depending on the severity of the accident, there
may also be far wider social and environmental
costs which result
With very serious accidents, the social and
environmental consequences can be extreme, and
may persist for many years, or even decades
Accident Outcomes
