1. RC-271 Safety Principles & Practices Accident Causation And Analysis

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

3. 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

4. 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    

5. 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Internal standards are in place, but they are outdated or inadequate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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

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

13. 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

14. 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

15. 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

16. 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

18. 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

19. 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    

20. 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)

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