An accident is defined as unplanned, uncontrolled event leading to loss or an undesired event that results in physical harm to a person or damage to property.
Accidents need to be investigated for humane, economic and legal reasons. Humane to prevent an injury occuring again. Economic to reduce costs; costs from higher insurance premiums; costs from the investigation itself; costs from replacing the employee and costs from loss of face or loss of credibility. Legal reasons; to comply with the law, i.e. RIDDOR (the Reporting of Injuries Diseases and Dangerous Occurences); to reduce potential fines and in doing so potential claims.
Occupational safety is not the absence of accidents but the identification of accident causes and implementing measures to control these potential accidents.
Accident investigation is a tool to help prevent the accident occuring again.
Loss causation and the domino theory
Accidents are a result of failings in the health and safety management system. Accidents are rarely the result of a single event. The cause of the accident can split into active and latent failings. Active failures are the actions of the individuals involved in the accident. Latent failures are remote failings of the management system that could have been in place for long periods of time before the active failings resulted. Latent failures are often refered to as pathonogenic failings.
The model:
Lack of Control/ Basic Causes/ Immediate Causes/ Incident/ Loss
Loss includes injuries to people, property and processes
Incident is the result of contact with energy or substance
Immediate Causes includes sub-standard acts and sub-standard conditions
Basic Causes include Personal factors and Job factors
Lack of control is the result of inadequate standards, compliance to standards and inadequate programmes for safety.
Sub-standard acts and conditions are immediate causes of the accident. This is often the only thing that is investigated. For a truely in-depth investigation to occur a more thorough examination of underlying causes needs to be conducted. Substandard acts and conditions are often referred to as the symptoms of the accident.
The basic causes are the real causes behind the symptoms. Basic causes are the reasons that unsafe acts and sub-standard conditions occur. Job Factors include poor supervision, leadership, purchasing, engineering, maintenance, equipment, tools, materails and work standards. Personal factors include inadequate capabilities, lack of knowledge and competence to carry out the task, lack of skill, stress (physiological and psychological) and improper motivation i.e. cutting corners.
Lack of control includes inadequate policies, management systems, and control systems. Inadequate standards include poor rules and a lack of compliance to rules. Loss of management control.
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