RC-271 Safety Principles & Practices Accident Causation And Analysis

A Thought to Ponder ... “Prescription without diagnosis is malpractice, whether it be in medicine or management.” Karl Albrecht Organization Development

ILCI Loss Causation Theory Inadequate MANAGEMENT control Basic causes: personal vs. job factors Immediate causes: substandard acts/ conditions Near hit/accident: contact with energy, substance, and/or people Loss: people, product, service, equipment, facility, and/or environment

THE ILCI LOSS CAUSATION MODEL LACK OF CONTROL Inadequate  Program  Program Standards Compliance to Standards BASIC CAUSES Personal Factors Job Factors IMMEDIATE CAUSES Substandard Acts & Conditions ACCIDENT/ NEAR HIT Contact With Energy, Substance or People LOSS People Property Product Environment    

Inadequate Management Control A lack of internal standards designed to reduce/eliminate risks to loss Hazard recognition and abatement Performance appraisal Employee/management communication Internal standards are in place, but they are outdated or inadequate Management and/or employees do not follow established internal standards

Basic Causes Job Factors Personal Factors Inadequate ... supervision engineering purchasing maintenance tools/equipment work standards Wear & tear Abuse or misuse Personal Factors Inadequate ... physical capacity mental capacity Excess ... physical stress mental stress Lack of ... knowledge skill Improper motivation

Immediate Causes: Substandard Acts Operating equipment without authorization Failure to warn Failure to secure Operating equipment at improper speed Removing safety devices Improper use of personal protective equipment Servicing equipment in operation Being under the influence of alcohol/drugs Horseplay

Immediate Causes: Substandard Conditions Inadequate guards/barriers Inadequate personal protective equipment Inadequate warning system Fire/explosion hazard Poor housekeeping Noise/radiation exposure Temperature extremes Inadequate illumination Inadequate ventilation

Near Hit/Accident Struck by or against Fall on same or to lower level Caught in, on, or between Contact with ….. Overstress, overexertion, or overload

The Loss People: A bruise to a fatality Product: A dented package to a destroyed shipment Service: A few minutes lost to a month delay Equipment: A broken part to a destroyed machine Facility: A cracked window to a leveled building Environment: An air emission to contaminated groundwater

Basic Elements of a Near Hit/ Accident Reporting System Develop agreed upon reporting standards Routinely remind supervisors and employees of the need to report near hits & accidents Maintain accurate records (computer-based) Use data to identify accident/near hit trends Routinely provide management and hourly employees with trend analysis results

Equipment for Collecting Near Hit/Accident Evidence Flash camera w/extra film & batteries Disposable Digital Camcorder Tape measure Grid paper

Importance of Immediately Gathering Perishable Evidence The 4 P’s of Perishable Evidence People: tend to forget or misrepresent Positions: become altered Parts: get changed and/or discarded Paper: can become altered and/or lost

Initial Actions at Near Hit/Accident Scene Take control (physical & emotional) Provide first aid and call emergency services Control potential secondary hazards Identify sources of evidence Preserve/gather evidence Notify appropriate line/staff management

The Near Hit/Accident Analysis Process Immediately collect the who, what, when, where, and how of the four P’s of evidence Identify the loss and loss-producing event Determine the most likely immediate cause Perform an Ishikawa (e.g., cause-effect) analysis on the immediate cause Test for most probable uncontrolled risk factors Develop & implement control measures for at least 3 uncontrolled risk factors

Traffic Crash Scenario Compact car approaches a stop sign Motorcycle is approaching from car’s right Driver of car pulls out in front of motorcycle Motorcycle strikes car on right side Cycle rider is killed instantly Driver of car is severely injured

Traffic Crash Scenario (cont.) Local law enforcement agency must perform an Ishikawa diagram to analyze the following major independent variables: Equipment n Processes/practices Materials n Environment People

THE ILCI LOSS CAUSATION MODEL LACK OF CONTROL Inadequate  Program  Program Standards Compliance to Standards BASIC CAUSES Personal Factors Job Factors IMMEDIATE CAUSES Substandard Acts & Conditions ACCIDENT/ NEAR HIT Contact With Energy, Substance or People LOSS People Property Product Environment    

THE ILCI LOSS CAUSATION MODEL LACK OF CONTROL Inadequate  Program  Program Standards Compliance to Standards BASIC CAUSES Personal Factors Job Factors IMMEDIATE CAUSES Substandard Acts & Substandard Conditions ACCIDENT/ NEAR HIT Contact With Energy, Substance or People LOSS People Property Product Environment     THE ISHIKAWA (FISHBONE) DIAGRAM Car enters cycle’s path (Cause) (Effect)

ISHIKAWA (FISHBONE) DIAGRAM Car enters cycle’s path People Equipment Procedures Car enters cycle’s path Materials Environment