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How and why accident happen
- 1. How and why incidents HAPPEN ISAD 105
- 2. To effectively explain how and why accidents occur, we will look on theories that better explained the result of complicated interactions taking place among conditions, behaviors and systems.
- 4. This theory is based on the ‘assumption that an accident is consist of a single event that has a cause. The investigative task is easy: find the cause and correct it, and you will prevent accidents.
- 5. An accident is thought to be the result of a single, one-time easily identifiable, unusual, unexpected occurrence that results in injury or illness. Usually, all responsibility for the accident is placed on the shoulders of the employee.
- 6. Worker’s error. Old thinking about the causes of accidents assumes that the worker lacks common sense or makes a choice to work in an unsafe manner.
- 7. Common sense as an invalid concept. When we assume common sense is a valid concept, it allows us to more easily place blame for accidents squarely on the shoulders of the employee. The Common sense excuse for accidents infers the employee is "the problem." To prevent accidents, the employee must work more safely. Thinking that accidents are due to a lack of common sense results in short-term fixes that are inefficient, ineffective, and in the long run more expensive to implement and maintain.
- 9. An accident as a series of related occurrences which lead to a final event which results in injury or illness. Example: ancestry and social environment - worker fault - unsafe act together with mechanical and physical hazard – accident - damage or injury.
- 10. The accident investigator who has adopted this approach will assume that by eliminating any one of those actions or events, the chain will be broken and the future accident prevented.
- 12. Accidents are the result of a series of random related or unrelated actions that somehow interact to cause the accident. An accident investigatigator will not only recommend corrective actions to remove the sharp surface, it will also address the underlying system weaknesses that caused it.
- 13. According to this theory, the contributory factors can be grouped into the following two categories: Behavioural. This category includes factors pertaining to the worker, such as improper attitude, lack of knowledge, lack of skills and inadequate physical and mental condition. Environmental. This category includes improper guarding of other hazardous work elements and degradation of equipment through use and unsafe procedures.
- 14. Two basic causes of accidents Unsafe Acts - The human action that departs from a standard job procedure or safe practice, safety regulations or instructions Unsafe Conditions - The physical or chemical property of a material, machine or the environment which could result in injury to a person, damage or destruction to property or other forms of losses.
- 15. Unsafe Acts Operating Equipment without Authority Disregard of SOP or instructions Removing Safety Devices Using Defective equipment Using improper PPEs or Using PPEs improperly Horseplay Working in an unsafe posture Absent- mindedness / Nervousness Willful intent to injure Working while under the influence of alcohol or drugs Improper lifting and carrying Lack of knowledge or skills Failure to understand instructions
- 16. Unsafe conditions can be grouped into 5 categories: Task - the actual work procedure being performed at the time of the accident is looked at. Material - possible causes resulting from the equipment and materials used. Environment - The physical environment, including sudden changes to it, are factors that need to be identified. Personnel - The physical and mental conditions of those individuals directly involved Management - Holds the legal responsibility for safety in the workplace
- 19. Additional cause System weaknesses. Underlying inadequate or missing policies, programs, plans, processes, procedures and practices that contributed to the accident.
Editor's Notes
- In companies which decide to take the risk, it's likely its attitude about accidents is, "accidents just happen; there's nothing we can do about them." Of course, that's an unacceptable notion in any effective safety culture. Employers with a healthful attitude about accidents consider them to be "inexcusable," and demand hazards be corrected before they cause an accident.
- Over the past century, safety professionals have tried to more effectively explain how and why accidents occur. During the early years the initial explanations were at first rather simplistic. Theorists gradually realized that it was not sufficient to explain away workplace accidents as simple cause-effect events. They developed new theories that better explained the result of complicated interactions taking place among conditions, behaviors and systems. With this in mind, let's take a look at some of these theories. Each different theory affects the purpose, scope and method of investigation of accidents.
- An accident investigator who has adopted this explanation for accidents will never look beyond perceived personal employee flaws to discover the underlying system weaknesses that may have contributed to the accident.
- According to W.H. Heinrich (1931), who developed the so-called domino theory, 88% of all accidents are caused by unsafe acts of people, 10% by unsafe actions and 2% by “acts of God”.
- Heinrich suggested that removal of one of the factors would prevent the accident and resultant injury;
- This explanation takes us beyond the rather simplistic assumptions of the single event and domino theories. Once again, accidents are not assumed to be simple events. They are the result of a series of random related or unrelated actions that somehow interact to cause the accident. Unlike the domino theory, the investigator realizes that eliminating one of the events does not assure prevention of future accidents. Removing the sharp edge of a work surface does not guarantee a similar injury will be prevented at the same or other workstation. Many other factors may have contributed to an injury.
- 80-90 percent of all accidents are caused by unsafe acts of people, as opposed to unsafe mechanical or physical conditions. Human failure is the primary cause of accidents!
- 1. Task Was a safe work procedure used? Did conditions change to make the normal procedure unsafe? Were the appropriate tools and materials available and used? 2. Equipment failure? If so, what caused the failure? Was the machinery poorly designed? Were hazardous substances involved? If yes, were they clearly identified and properly labeled? Was the raw material substandard in some way? Was PPE used? If yes, was it appropriate for the task being performed and was it in “serviceable condition?” 3. What were the conditions in the work area (example: cold, hot, damp, etc.)? Was poor housekeeping a problem? Was noise a problem? Was there adequate light? Were toxic or hazardous gases, dusts or fumes present? 4. Was the employee experienced in the work he/she was doing? Was the employee adequately trained for the task being completed? Can the employee physically perform the work? Was the employee under work or personal stress at the time of the accident? 5. Were safety rules communicated to and understood by all employees? Were written procedures available? Were the procedures/rules being enforced? Was there adequate supervision?