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Accident causation is realistically based on an assumption that employees in large-small, organisations are not required to understand the concept of safety; instead they are taught to understand and adopt the concept of 'safe-working practices'. Employee preconceptions involving cultural understanding of safety aspects can be extremely diverse within an organisation, leading to the "social" development of a "safety culture". Issues of ambiguity play a pivotal part in accident causation analysis since there is a large consensus, (right or wrong) on what constitutes 'safety' on the one-hand; and what constitutes danger alarmingly fluctuates across many business sectors, (Gherardi, Nicolini, and Odella, 2002). (Heinrich, 1941) offered the first real adaptation on cause-effect relationship or "linear" one-by-one "progression" of events-accident causation, known as the "domino theory". Accident causation models seek to make sense of accident-scenarios-situations by way of explanation-analysing the root cause processes relevant to implementing safety initiatives. Accidents by way of definition occur in all sectors across all business, and prevention requires a thorough understanding of the mechanisms involved in the process, (Suraji, Duff, and Peckitt, 2001). Conversely methods of accident investigation and its development-understanding have gradually highlighted a momentum shift from a single immediate causation factor, to aspects of multiple sequences of event failures which may have occurred as a result of organisational latency factors.
The primary aim of this paper is to compare and contrast the effectiveness of accident causation theory in investigating small scale occupational accidents and larger scale industrial incidents. Identifying and evaluating factors which influence the identification of suitable for application accident-causation and investigation theories. Using peer reviewed papers, incorporating their merits, limitations and the effectiveness of strategies employed in current accident causation methodology.
SMALL SCALE OCCUPATIONAL ACCIDENTS:
WORK ACIDENTS INVESTIGATION TECHNIQUE (WAIT):
Originally developed by (Jacinto, and Aspinwall, 2003a) derived from approaches conceptualised by (Reason, 1997) and (Hollnagel, 2002). Initial the process has two "sequential" phases, firstly a questionnaire-investigation allowing for information assembly-criteria: Where; Who; How. Secondly a comprehensive analysis process of the management-organisation.
Sequence one deal with "Active failures" in the analysis process, aspects of events-consequences, identifying underlying factors; employee's working-environment and workplace situations. Sequence two is a more thorough analysis: individual(s); work-practices; then focuses on managerial-organisational factors. There are 9 steps to the investigation process; 4 deal with legality, statutory-requirements, 5 deal with organisational-managerial deficiencies, allowing for improved standard-operating-procedures, policies, training regardless of whether an occupational safety system is present or not, (HSG:65; OHSAS-18001).
Steps 1-4 Initial Investigation Process:
Basic information collation (Standardised-questionnaire provided).
Establishing "Active failure" (potential-likelihood severity-consequences).
Identification of influencing-contributing elements (workplace-environment).
Identify-compare with existing Risk Assessment(s) (amend if required).
Steps 5-9 Organisational review analysis-process:
Thorough analyse of employee-individual(s) working practices.
Review current organisational-managerial attitudes to policies standard-operating-procedures.
Review-link outlined findings to current H&S management system - (WAIT) advises the use of (OHSAS-18001), however (HSG: 65) uses similar process techniques.
Ensure all findings-recommendations are acted upon, (timescales, by whom).
Highlight any positive-influencing elements, (good-practices; working methods introduction into other areas).
The 9 step process that (Jacinto, and Aspinwall, 2003b) advocate looking at distinguishing aspects between impact factors-errors of individual(s), workplace-environment; against aspectual deficiencies of organisational-managerial triggers outlined by (Reason, 1990a) as "active & latent" failures.
"Active Failures", steps 1-4 are the immediate casual impact made up primarily by FLT machine-plant operators, warehouse-staff, usually classified as the combination or direct-cause of the accident phase.
"Latent Failures", steps 5-9 can be classed as predisposed 'active failures' representing aspects of the organisation-management and result in 'latent failures'.
Common associations of latent failures include: Inappropriate design of machinery-equipment-layout-controls; ineffectual training-instruction-information-supervision; lack of timely or effective communication, management-employee ambiguity of responsibilities-roles job-selection. Identification of "Latent failures" presents an organisation with the ability-opportunity to target weakness, crucially allowing for an appropriate accident control-prevention strategy adjustment. Unresolved latent failures increase the probability-likelihood of further incident-accident scenarios irrespective of active failure interventions, often a single latent failure impacts onto numerous other errors often with catastrophic consequences. Removal-elimination of latent situations may directly influence costs and may prevent accidents.
KING'S CROSS UNDERGROUND STATION FIRE.
Latent Failures: 31 People Killed
"In summary it was found that numerous instances of minor escalator fires had been investigated-recorded, the organisation took a view-point that there was a threat of a major escalator fire but took no direct action, as the inquiry stated". "Furthermore the inquiry stated that little real effective action-measures had been undertaken in order to mitigate further reoccurrence provided by the initial warning fires". "The inquiry also stated in the report that there were numerous-serious flaws within the management and organisations understanding of ownership-responsibility towards passenger(s) Health & Safety as a priority, and was in fact someone else's problem to deal with".
The "London Underground operator's" significantly underestimated the crucial implications of not addressing specific latent issues within the organisation which had almost certainly been present for years. The enquiry clearly outlines that if managerial-organisational latent misconceptions and attitudes towards safety had not been thoroughly scrutinised along with its deficiency preconditions, a further likely outcome may have ensued, (Department for Transport, 1987).
LARGER SACLE INDUSTRIAL INCIDENTS: TRIPOD OIL-GAS and HI-TECH INDUSTRIES APPLICATION:
Once again follows (Reason, 1990b) causation model theory, and focus primarily on organisational types of hierarchal failures. Tripod focuses on the "barrier" control-defences and their subsequent failure for analysis. Developed in the mid 1990's as a joint venture between the University of "Leiden" (Netherland) & University of "Manchester (UK), (Wagenaar et al., 1994). The main focus of attention can be attributed to (System-Active-Latent failures) which feature as a direct sequence of events leading to mechanisms of underlying organisational failure types, or more precisely (GFTs) or "General Failure Types, and comprise of 11 specific type failures scenarios. E.g.
"Preconditions are the environmental, situational or psychological 'systems states' or 'states of mind' that promote or directly cause active failures".The 11 (GFTs) represent potential deficiency conditions within a working situation. Tripod's primary aim is to analysis the deficiencies (Bar-graph) highlighting which of the 11 (GFTs) are deficient across the organisation. One of the interesting aspects of Tripod as a concept unlike (WAIT), it links two further mechanism's into causation cycle. Firstly a link is established between the ("active-latent") failures or the "Preconditions" also known as the "psychological precursor" (Reason, 2000).
"Ineffectual decisions-actions, normally outside of the business end; usually ends in ineffectual safety or ineffectual management safety systems".Secondly the link outlines the responsibility of the "policy maker" the first link in the chain, also the final link in the causation chain.
TRIPOD BARRIER CONTROL/DEFENCE TREE.
SYINOPSIS of the 11 (GFTs):
HARDWARE: Normally associated with material-hardware construction failures, (e.g. ware-ageing) equipment design, either through poorly maintained or poor manufacturing processes.
DESIGN: Ineffectual layout of equipment-plant. Incorrect tool-equipment selection usage-misuse, leading to unsafe acts, increasing potential errors, resulting in rule-procedural violations.
MAINTENANCE MANAGEMENT: Testing of plant-facility equipment; emergency-shutdown procedures; inspection-surveys.
PROCEDURES: Standard operating procedures; Risk Assessments; Engineering controls; out of date processes.
ERROR-ENFORCING CONDITIONS: Time constraints leading to errors-violation, unsafe practices; Shift working patterns; Lone-working; Physical conditions, (Extremes of cold-heat, noise), Permit-to work-systems.
HOUSEKEEPING: Use of adequate personnel; lack of understanding; time constraints.
INCOMPATIBLE GOALS: Direct conflict between company prerequisites safety-production targets rules-procedures; social-cultural development of rules-procedures deviating from established written procedures.
COMMUNICATION: Lack of prescriptive-effective dialog between parties. Clear unambiguous messages from the top-to-the-bottom of the communicatory chain within an organisation. Most accident-analysis usually outlines communication as a contributory factor.
ORGANISATION: Structure deficiencies usually allowing for safety responsibilities to take a back seat within the business. Overlooking warning signs, not prioritising smaller type incidents, not complying with stated safety intentions.
TRAINING: Ineffectual in providing required awareness skills, mentoring, on job coaching, providing formal courses, along with periodical refresher training.
DEFENCES: System failures, control-containment of hazard(s), pressure valves, flow-restrictor devices, and human-component mitigation as a direct-indirect consequence.
'Defenses' is specifically the only "Latent Failure" concerned with SAFETY. All other (GFT's) are related to practical-suitable and effective management strategies.
PIPER ALPHA OIL RIG FIRE.
System/Latent/managerial Failures: 167 People killed.
"The Cullen Inquiry"
In November 1988 Lord Cullen commissioned an enquiry into the disaster in two parts, firstly to establish the primary cause of the disaster. Secondly the enquiry looked to facilitate recommendations for proposed changes in safety regimes.
"The concern for safety was permitted to co-exist with working practices which were positively catastrophic". "The best of intentions regarding safe working practices was permitted to go hand-in-hand with the worst of inaction in ensuring that such practices were put into effect". "In summary the inquiry concluded from the evidence that the quality of safety management is fundamental to off-shore safety". "No amount of detailed regulations for safety improvements could make up for deficiencies in the way that safety is managed".
E.g. Taken from the report into the Piper Alpha disaster:
ACCIDENT CAUSATION FRAMEWORK EVALUATION:
(Wagenaar, van der Shrier, 1997b) speculate that a typical accident causation model requires six elements of an investigation procedure in order to fully to under-pin a quantifiable outcome for analysis, (e.g. "Revealing" "Quantitative" "Valid" "Reliable" "Practical" & "Consequential"). However to fully develop an accident causation framework, the "user" perquisites must be also fully considered prior to its introduction. Differing accident causation approaches directly affect the investigation methods of each user.
In order to effectively consider and accident causation methodology, it's important to understand what types of accidents are being investigated, along with the required complexity of the analytic prerequisites which influence the methods, and the view point of the investigator, (Jacinto, 2003).
Accident Causation Framework Evaluation Method:
Evaluation Method Requirements Industry Application
Descriptive Revealing Consequential Validation Practical
TRIPOD YES YES YES/NO YES YES Used in high-tech industries Oil-Gas
WAIT YES YES YES YES YES Used in/across all Occupational
"Yes denotes the method and if it conforms to the requirements, YES/NO denotes it might conform, to the requirements".
TRIPOD and WAIT can both trace their origins back to (Reason, 1990) and can be grouped accordingly. TRIPOD falls under the organisation or (Systemic) area of accident causation theory, whereas WAIT looks at concepts of (active-latent) failures. However both methods are explicitly derived from (Reason's) model. WAIT-TRIPOD intended purposes are to seek out aspects of casual sequences deep rooted within the organisation, (Latent factors) from workplace scenarios; to (individual-team failures) rule-violations; (active failures) and failed "defences". TRIPOD also looks at organisational failures as the main factor in "accident causation"; an occurrence is treaded as a failure, (e.g. barrier-control breach) or an (active failure), once identified TRIPOD searches for the "Precondition" casual effect, (active-latent) condition(s) and seeks to identify the targeted weaknesses, both methods actively seek to identify organisational "Latent" Conditions. However both casual framework methods do not provide specific-practical solutions due to their general nature and application interpretation as a user method. (Lehto, Salvendy, 1991).
The morphology of accident investigation and its development-understanding have gradually highlighted a momentum shift from single immediate causation factors, to aspects of multiple sequences of event failures which may have occurred as a result of organisational-managerial deficiencies within the working environment. Selection of a suitable accident causation framework depends on various specific factors.
Firstly accident causation models primary development function was to investigate major accidents in highly complex industries; therefore limiting their use in ordinary occupational situations.
Secondly it's important that when choosing a model that it's fit for purpose, that credible information can be extrapolated from the investigation method, which outlines the "Latent" problems as well as the "active" impact principles, in order to establish whether the accident model fits the accident investigation profile. Further considerations involve conceptualisation aspects of the user; and the effect this may have on the investigation process. Suitability of both the user and the system along with the methods used to evaluate the efficacy-effectiveness of both in application will be difficult to measure objectively and may not be suitable for outcome.
An accident causation model provides the framework necessary to instigate an investigation process, which in turn provides the knowledge-mechanisms outlining an accident causation profile. An initial step for any potential investigator would be to choose a system which not only fits the organisations profile, but one which suits him/her and should be based on the criteria contained within Table 1. However there is still no legal requirement to investigate accidents, WAIT would be an appropriate tool to use as part of a company's commitment to investigating all accidents as WAIT is best used in conjunction with a suitable management system, (e.g. HSG:65-OHSAS-18001). The use of management system in-tandem with WAIT could highlight where WAIT ends for instance and a local investigation procedure may be more productive, or where a more complex investigation methods need to be applied. E.g. Independent Chair of enquiry, use of (RCA) root-cause-analysis methods, as some incidents may dictate this policy as they may be RIDDOR prescriptive in nature, this is where TRIPOD may take over.
Root cause is nearly always the main driver behind organisational-managerial latent deficiencies in establishing the real reasons in the culmination of all accidents-incidents, as outlined by the King's Cross Underground Station Fire, and The Piper Alpha Oil rig Disaster. Conversely it would be an effective approach method, to use a combination of model causation-method analysis when investigating small scale occupational accidents and larger scale industrial incidents. However human factors or cognitive volition still remains in its infancy with most complex investigation tools merely highlighting human factors as a potential cause, but not going any further into the realms of human behavior.
CAUSATION MODEL THEORY REPRESENTATION
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WORK ACCIDENTS INVESTIGATION TECHNIQUE (WAIT)
FLOWCHART STAGE 1
"Collect information through direct observation and by interviewing all people involved in the occurrence, whether or not they were injured. These people will provide their own description of the accident sequence and their part in the events. At the end of the interview, distribute to each person a list of standard questions, which may help to draw attention to other less obvious facts, and disclose further relevant information". "Standard questionnaire is provided".
Identifying all active
"Decide which events constituted "active failures" by systematically searching through all the following possible categories: HUM (humans), E&B (equip. and buildings), HAZ (hazards), LOR (living organisms), and NAT (natural phenomena)".
"To help with the words, you may find it useful to use the checklists provided (classification schemes for all 5 categories)".
"Display all active failures in a table (column 1 of the table) in
chronological order - register each single event in one row".
Establishing the applicable
"For each active failure, search for possible "influencing factors", which might have facilitated or triggered the failure under consideration". "To do this, use the answers to the questionnaire in step 1, combined with the classification lists provided".
"If more than one factor is encountered, subdivide the particular row - displaying the findings in column 2".
"Repeat the search for each row of column 1 (each active failure)".
Review the analysis and gather more information if necessary
with relevant Risk
Assessment(s) - RA
"Compare all findings of columns 1+2 with relevant risk assessments". "Risk Assessment is a legal and fundamental duty". "Check if the hazards, human failures, and risks involved in that particular occurrence had been actually considered in the risk assessment(s)". "If RA exists and all risks were considered, ask why it failed to prevent that particular case". "Establish whether or not the applicable RA is good enough or needs improvement".
"The record of the risk assessment itself may draw your attention to other possible problems, either active failures or influences, which were not mentioned in the previous steps".
Other failures or factors could be identified as
"Step 4 will help the investigator to determine if the previous ones are complete and whether the relationships encountered are logical, coherent and consistent". "If no more relationships are found, this is the END of the basic investigation, and an in-depth analysis can be performed whenever necessary". "In-depth analysis goes beyond official reporting duties and companies should have a criterion for deciding which cases need a full or in-depth investigation".
WORK ACCIDENTS INVESTIGATION TECHNIQUE (WAIT)
IN DEPTH INVESTIGATION FLOWCHART STAGE 2
"For each new row of column 2, search for human factors - within the individual(s) and the job, or working system - which are believed to have contributed to the active failures and their influencing factors". "Note: the number of initial rows will probably have increased in column 2, by adding the context in which active failures occurred". "Consider each one of them. To help the search, use the classification scheme provided for individual and job factors".
"If more than one factor is found, then, subdivide each row again, and display the results in column 3".
Analysing individuals &
Include new factor(s) in
column 2 - and review
the analysis from step 4
Analysing organisational &
"For each new row of column 3, search for organisational and management factors or conditions which may have facilitated, or may explain, why the previous events occurred". "Use the classification scheme provided, to help identify such weaknesses in a systematic manner".
Display the results in column 4.
More Influencing factors were identified?
"For each new row obtained in column 4, verify if any other "influencing factor" is necessary to help explain cause-effect relationships". "The in-depth analysis only STOPS when no more cause-effect relationships can be established". The table is now complete.
"On a separate form, link the general management problems encountered to your own H&S Management System". "Notice that a particular problem, such as, "inadequate management of contractors", may have to be linked to different elements of the system (e.g.: planning or implementation)". "If your company does not have a formal system, this is a good opportunity for prioritising needs in terms of implementing one. In WAIT, a standard OH&S Management System (the OHSAS 18001:1999) will be used as a model for establishing the links".
Linking findings to H&S
"Based on the results of the analysis (basic + in-depth), make a list of recommendations and propose a plan of action". "Whenever possible, include the following information: Recommended action / responsibility for executing / time expected for completion / rough estimation of cost / expected benefits/ priority".
"Re-analyse the case from a different point of view - this time searching for the existence of "positive influencing factors". "To do this, re-analyse all information and, if necessary, re-interview people under this new perspective". "In addition, highlight the benefits of "good practice" (if it was present) so that other co-workers can appreciate successful behaviours and realise their importance".
Searching for positive
Influencing factors were identified?
"If positive influences or circumstances are found, establish whether they are merely a "random" coincidence, or if they are of a "controllable" nature - thus providing clues for new or better preventive / protective measures". "If so, review step 8 and include them in the recommendations".
End No (or only random-not possible to control)