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EUCOSH Projecton OSH in High Risk

Sectors

ACCIDENT INVESTIGATION AND PREVENTION PRINCIPLES

Antero Vahapassi

WORKSHOP ON WORK SAFETY RESPONSIBILITY SYSTEMS WITHIN OSH INSPECTION SYSTEMS

15 – 16 APRIL, 2014, IN GUOLIN HOTEL, BEIJING

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What is an Incident?

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Definition of an Incident

• An incident usually refers to an unexpected event that did not cause injury or damage this time but had the potential.

• "Near miss" or "dangerous occurrence" are also terms for an event that could have caused harm but did not.

• The term incident is used in some situations and jurisdictions to cover both an "accident" and "incident".

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DEFINITIONS OF ACCIDENT (1)*

Occupational accident: An occurrence arising out of or in the course of work which results in:(a) fatal occupational injury;

(b) non-fatal occupational injury resulting in incapacity for work of at least three consecutive days, excluding the day of the accident

* From the ILO code of practice, Geneva, ILO, 1996 [This definition has been approved also by EU (Eurostat)]

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European statistics onaccidents at work (ESAW)

Consequently, "more than 3 days" means "at least 4 days", which implies that only accidents with a resumption of work not before the fifth day after the day of the accident or later should be included.

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Categorizing other incidents

• Serious or major accidents (e.g. fatal accidents, and those causing permanent invalidity)

• Over 3-day lost time accidents• Minor accidents (only first-aid

needed)• Non-injury or property damage

incidents• Incident with No-visible injury or

damage (“near misses”)

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Why we are interested in incidents at work?

• We want to know why they happened.• We want to know how to prevent them?• We want to know if something is wrong in our

working or production processes.• It is a legal requirement to report them.• We want to compensate the victim.• Someone wants to know if laws or safety

rules have been broken.

incidents must be reported and all serious incidents must be investigated!!!

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An accident iceberg is a metaphor or a symbol for the ratios between major and minor accidents and injuries, and the following two pictures refer to two different accident studies. Accident iceberg is also used to characterize insured and uninsured accident costs (see below):

Often uninsured cost vary from 2 – 36 times more than insurance costs according to the studies in UK.

Costs not covered by insurance can include:

• sick-pay;• damage or loss of product and raw materials;

• repairs to plant and equipment;• overtime working and temporary labour;• production delays;• investigation time;• fines.

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As examples, two different accident studies of an accident iceberg are presented here, i.e. by Frank E. Bird (1969) and HSE Accident Prevention Advisory Unit (APAU), 1997

APAU, 1997

Frank E. Bird, 1969

All these studies indicate that every major accident will have also 10-20 minor accidents or injuries, around 50 property damage incidents, and 300-500 “near misses”.

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Accident Investigation

IMPORTANT: Accident investigation is a different task from accident reporting (notification).• All serious accidents (fatalities and more than

30 days absenteeism) must be investigated by the labour inspector (and reported beforehand).

• All ‘more than 3-day’ accidents must be reported according to the official system either to the Workmen's Compensation (insurance) or the State Statistical (or Social Security) Bureau

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Accident Investigation

• The purpose of the accident investigation is to determine the cause of accidents in order to implement preventive measures, not to find out a guilty person(s).

• The person conducting an accident investigation must be trained.

• Often accident investigation is done by a team of specialists.

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History of causation

• In one of the earliest reports on the subject, Mr. Heinrich, in his 1928 study of 75,000 accidents, established the much-quoted 88:10:2 ratio.

• He concluded that 88 per cent of all accidents were caused by unsafe acts, 10 per cent by unsafe conditions and 2 per cent by conditions which could not have been prevented.What do you think? Is this ratio correct?

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History of causation (cont.)

• However, in this classical study, only one cause for each accident was reported, and, as we will see later, accidents are the result of a number of interdependent factors.

• Furthermore, when Mr. Heinrich recognised accidents to be results of unsafe acts and unsafe conditions, he selected what he considered to be their major cause.

• Consequently, this ratio is now considered by many to be invalid. If anything, the ratio is far more likely to be nearer 1:1, between unsafe acts and unsafe conditions.

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Multiple-cause theory

An example of a well-known multiple-cause theory is: a domino theory

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Domino theory

A= the root cause, B= the immediate cause

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Incidents (or accidents) do not just happen, they are

caused• Industrial accidents are the end

results of unsafe acts and unsafe conditions at work.

• However, accidents are preventable - they don't just occur spontaneously.

• They usually occur as a result of a combination of a number of factors. The three main sets of causes are:- organizational causes,- technical causes and- human causes.

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What causes are the most common (a study from Finland)?

All fatal accidents are investigated in Finland and concerning the three groups of causes, the following distribution has been found:

• Technical and physical factors were 33 %,

• Factors related to activities of persons were around 12 %, and

• Organizational factors were around 49 %.

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Accident model

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Accident model (cont.)

• An accident or a possibility of getting sick (an occupational disease) will always exist when man and hazard come in contact at the same time, in the same place.

• Determining exactly which hazard (risk) may be responsible for an accident, is not always easy or quite as simple as it seems.

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Accident Investigation in practise

• Accident/Incident investigation at the enterprise level or by the OHS authorities should always be divided into two phases:

1. Finding out what happened (the progress of accident/incident), and

2. Finding out the causes of the accident or incident

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I. Progress (what happened)?

• who is the informant (name and duty),• place where the accident happened,• who is the victim,• when the accident happened,• short description of the accident,• consequences of the accident,• where the victim is now,• have the police or labour inspectors

been informed, and• any other additional information.

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II. Causes of an accident

• Determining the progress (what happened) of an accident is like detective work (information collection, interviewing staff, taking photos, observing the accident scene and working environment, etc.).

• Subsequently, all the data and information needs to be analysed: establishing the causes of the accident/incident.

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Causes of the accident (cont.):

Three principlesi) Complexity (many causes)

Generally speaking, it is never a question of simply one factor or cause of an accident, but of several causes which have often no correlation with each other. It is the combination of these factors that causes the accident to occur.

ii) Significance (importance)Different causes do not affect the occurrence of an accident in the same way. Each cause has an effect of its own. Therefore, the significance of the causes should be determined, e.g. which is the most impor tant cause, and which is second in importance, etc.

iii) The sequence of causes (the chain of causesdomino)The sequence, or the order, of the separate causes is significant; in a way the causes are like a chain which leads to the acci dent. This chain must be discovered and broken in accident prevention.

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ACCIDENT PREVENTION

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PRINCIPLES OF ACCIDENT PREVENTION

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“Eliminate, minimise, control” EU’s Framework Directive, Article 6.2

1. avoiding risks;2. evaluating the risks which cannot be avoided:3. combating the risks at source;4. adapting the work to the individual, especially as regards the

design of work places, the choice of work equipment and the choice of working and production methods, with a view, in particular, to alleviating monotonous work and work at a predetermined work-rate and to reducing their effect on health.

5. adapting to technical progress;6. replacing the dangerous by the non-dangerous or the less

dangerous;7. developing a coherent overall prevention policy which covers

technology, organization of work, working conditions, social relationships and the influence of factors related to the working environment;

8. giving collective protective measures priority over individual protective measures;

9. giving appropriate instructions to the workers.

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Murphy's Law

• When a designer or planner cannot eliminate a hazard, or the possibility of an accident completely, he must attempt to minimize the possibilities that other persons will commit errors generating mishaps. In effect, the designer, through foresight, must attempt to make the system 'fool-proof', although he knows he will always be subject to the inevitability of Murphy's Law.

• The most important fact in accident prevention is that accidents do not just happen; they are caused. This also means that accidents are preventable.

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THANK YOU FOR YOUR ATTENTION!

谢谢您的关注 !