Transcript Unit 2

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
2
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
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THE ILCI LOSS CAUSATION MODEL
LACK OF
CONTROL
BASIC
CAUSES
IMMEDIATE
CAUSES
ACCIDENT/
NEAR HIT
LOSS
Inadequate
 Program

 Program
Standards

Compliance
to Standards

Personal
Factors
Job
Factors



Substandard
Acts &
Conditions



Contact
With Energy,
Substance
or
People



People
Property
Product
Environment
4
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outdated or inadequate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
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Basic Causes
Job 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
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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
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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
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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
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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
10
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
11
Equipment for Collecting
Near Hit/Accident Evidence

Flash camera w/extra film & batteries
 Disposable
 Digital

Camcorder

Tape measure

Grid paper
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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
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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
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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
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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
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17
Traffic Crash Scenario (cont.)

Local law enforcement agency must
perform an Ishikawa diagram to analyze
the following major independent
variables:
 Equipment
 Processes/practices
 Materials
 Environment
 People
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THE ILCI LOSS CAUSATION MODEL
LACK OF
CONTROL
BASIC
CAUSES
IMMEDIATE
CAUSES
ACCIDENT/
NEAR HIT
LOSS
Inadequate
 Program

 Program
Standards

Compliance
to Standards

Personal
Factors
Job
Factors



Substandard
Acts &
Conditions



Contact
With Energy,
Substance
or
People



People
Property
Product
Environment
19
THE ILCI LOSS CAUSATION MODEL
LACK OF
CONTROL
BASIC
CAUSES
IMMEDIATE
CAUSES
ACCIDENT/
NEAR HIT
LOSS
Inadequate
 Program

 Program
Standards

Compliance
to Standards

Personal
Factors
Job
Factors



Substandard
Acts &
Substandard
Conditions



Contact
With Energy,
Substance
or
People



People
Property
Product
Environment
THE ISHIKAWA (FISHBONE) DIAGRAM
Car enters
cycle’s path
(Cause)
(Effect)
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ISHIKAWA (FISHBONE) DIAGRAM
People
Equipment
Procedures
Car
enters
cycle’s
path
Materials
Environment
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