Accident Causation

Accident causation
Rev: 1.1 11/04/01

“ An accident may be defined as an undesired event

that results in harm to people, damage to property, loss
of process and/or production.”

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 Accident Causation

Purpose
To minimise accidental loss and risk exposure to personnel, process,
production and equipment.

The following notes serve to assist all personnel to ensure that proper
standards are established, maintained and complied with, to prevent and
eliminate accident “loss” potential during all drilling and well servicing
operations.

Responsibilities
It will be the responsibility of all senior drilling representatives to ensure
that others with duties relating to safety management controls contained
within this document are aware of their responsibilities.

Scope
These procedures shall apply to all drilling personnel.

Further References
Drilling contractor’s and Operator’s mutually agreed specific safety
management and accident prevention procedures.

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 Accident Causation
Table of contents

ACCIDENT CAUSATION ............................................................................................................ 1

Purpose.......................................................................................................................................... 2
Responsibilities............................................................................................................................. 2
Scope............................................................................................................................................. 2
Further References ........................................................................................................................ 2
Table of contents........................................................................................................................... 3
ACCIDENT CAUSATION ............................................................................................................ 4
Lack of control.............................................................................................................................. 4
Basic causes .................................................................................................................................. 5
Immediate causes.......................................................................................................................... 7
Incident / Contact........................................................................................................................ 13
Loss............................................................................................................................................. 14
APPENDIX 1................................................................................................................................... 1
Accident or Loss Causation Model............................................................................................... 1
The loss Control Iceberg............................................................................................................... 2

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 Accident Causation

Accident causation
Lack of control
Without adequate management controls, the cause and effect sequence will
begin, that if not corrected in time, will result in accidents and loss occurring.

Managers, Leaders, Supervisors must thus plan to organise, lead, execute

and control operational activities more effectively. If not, then accidents will be
caused.

The three most common reasons for lack of control are;

1. Inadequate programs
2. Inadequate program standards
3. Inadequate compliance to standards.

Correcting these three reasons for lack of control is thus a critical

management responsibility.

Developing an adequate training program and standards is however an

executives function, that would be aided and recommended by supervisors.

Finally maintaining compliance with standards is a supervisory

function, aided by executives.

Accident “Loss” control is thus a management team effort, all

the way.

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 Accident Causation
Basic causes
Basic causes are the diseases or real causes behind the symptoms: i.e. the
reasons why substandard acts and conditions have occurred.
Factors take note that if identified at some stage in any unplanned event
and/or accident occurrence, could have permitted more meaningful
management and control to have taken place.

Often basic causes are referred to as the “Root, real, indirect, underlying
or contributory causes.” This is because the immediate causes i.e. the
symptoms , substandard acts and conditions are often quite apparent, but
is takes a bit of probing to get at the basic causes and some more effort to
gain control of them.

• Basic causes however can help explain why people perform

substandard practices.

• Basis causes can also assist to explain why substandard

conditions exist.

• Basic causes finally can be categorised into two major categories

i.e.

1. Personal factors

2. Job factors (work environment)

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 Accident Causation
Personal factors
Examples of personal cause factors are;
1. Inadequate capability
- Physical/Physiological
- Mental/Psychological
2. Lack of knowledge
3. Lack of skill
4. Stress
- Physical/Physiological
- Mental/Psychological
5. Lack of commitment
6. Lack of motivation

Job factors (work environment.)

Examples of job related factors are;
1. Inadequate leadership and supervision
2. Inadequate engineering
3. Inadequate purchasing
4. Inadequate maintenance
5. Inadequate tools equipment, materials
6. Inadequate work standards
7. Wear and tear
8. Abuse or misuse

Basic cause are thus the origins of substandard practices and conditions, how
ever, they are not the beginning nor the end of a cause and effect accident
sequence. What starts the sequence, ending in accidents and loss, is
however as stated previously due to “lack of control”.

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 Accident Causation
Immediate causes
If controls are thus not exercised as described in the previous sections, a
sequence of events and basic causes will occur where ultimately accidents
will be caused through both individual or a combination of substandard acts
and/or conditions;

1. Substandard “Unsafe” acts

or
2. Substandard “Unsafe”
conditions.
Substandard “Unsafe” acts are “behaviours which could permit the
occurrence of an accident.”

Substandard “Unsafe” conditions are “circumstances that could permit

the occurrence of an accident”

All things are hidden, obscure and debatable if the cause of

the phenomena is unknown, but everything is clear if the
cause is known. Louis Pasteur

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 Accident Causation
Substandard “Unsafe” acts:
1. Working rig-site and/or with equipment in operation or
without clearance
• Working without supervisory clearance or a work permit
as required.
• Working on Parts and Equipment still under pressure or
high temperature.
• Servicing of equipment in operation or still moving.
• Working on electronically charged equipment,
connections and line work.

2. Failure to wear personal protective equipment

• Failure to make use of Personal protective equipment (PPE)
such as goggles, gloves, safety boots, gasmask, safety hat, face
shield, apron, etc.

3. Wearing unsafe clothing

• Wearing unsafe personal attire such as slippery footwear,
loose long hair, long sleeves, loose tie, etc.

4. Failure to secure or warn

• Failure to lock, block or secure entrances, vehicles, moveables,
switches, valves, machinery and tools, materials and equipment
against unexpected/unwanted motion, flow of electric current,
steam, water compressed air, gas and similar agents.
• Failure to shut off equipment not in use.
• Failure to provide warnings such as: signs, signals, tags, etc.
• Releasing or moving loads without adequate warning.
• Starting or stopping plant, vehicles or equipment without
adequate warning.

5. Horseplay
• Distracting, teasing, abusing, startling, quarrelling, practical
joking, throwing material and tools, showing off, shouting and
making disturbance with intent.

6. Improper use of tools and equipment

• Use of materials, tools and equipment in a manner for which
it is not intended.
• Overloading of vehicles, scaffolds, cranes, equipment,
pressure vessels, power lines, etc.

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 Accident Causation
7. Improper use of hands and other parts of the body.
• Gripping objects insecurely
• Taking wrong hold of objects
• Using hands instead of tools
• Kicking instead of lifting or pushing

8. Unsafe or imporper placement.

• Inattention for obstructions to walking.
• Failure to secure safe foot placement on stairways and
ladders.

9. By-passing safety devices.

• Making safety devices inoperative.
• Blocking plugging, tying, disconnecting or removing safety
devices.
• Replacing safety devices, such as fuses and safety valves, with
those of improper capacity.

10. Unsafe speed.

• Operating or working at unsafe speed.
• Feeding or supplying too rapidly.
• Jumping from elevations and other unsafe speed.
• Running instead of walking.
• Throwing materials and tools instead of carrying or passing
them.

11. Unsafe position or posture.

• Taking unsafe position or posture.
• Entering restricted areas and enclosed spaces without
proper clearance or escort, as appropriate.
• Using transport in unsafe position, such as riding on
platforms, tailboards, forks of a lift truck, crane hook and similar.
• Unnecessary exposure to suspended loads, swinging loads and
materials or equipment in motion.

12. Operating errors.

• Violating rules, standards, operating codes and instruction as
valid and applicable to drilling equipment and equipment
systems.
• Failing to use safety devices
• Servicing equipment in operation.

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 Accident Causation
13. Unsafe operational acts.
• Injecting, mixing or combining one substance with another so
that unwanted reactions, explosion, fire or other hazard is
created.
• Unauthorised deviation from standard procedures and
instructions in respect of conditions, timing, sequence,
methods and materials to be used.
• Placing of materials, vehicles and movables in an unsafe
position for loading, unloading and manipulating.
• Unsafe placing of materials, tools, scrap and other objects so
as to create tripping, bumping, and slipping hazards.
• Failing to clean up work site at appropriate times during or on
completion of task.

14. Using unsafe or defective equipment.

• Making unauthorized modifications.
• Working with equipment obviously tampered with.
• Using defective tools and other agencies for work such as
slings, cable, moveable scaffolds, ladders, etc, in poor condition.

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 Accident Causation
Substandard “Unsafe” conditions
1. Defective tools and equipment
• Defects such as tools, equipment and similar aids, unfit for
the purpose and application they are intended for.
• Poor quality of design and materials.
• Dull instead of sharp, improperly assembled, worn, cracked,
frayed, broken, incomplete.

2. Defective design.
• Design of structures and buildings not in accordance with
standards and specifications if and as prescribed by
Company and/or law.
• Design of installations, machinery, plant and equipment
not in accordance with Company standards and/or
specifications.
• The application of materials and components conflicting
with standards and design specifications, such as ferrous
instead of non-ferrous, a lower class of pipe and line
components, normal steel instead of high tensile, etc.
• Designs which are not complete in respect of guarding
moving parts, provisions against accidental or
unauthorised access, devices against unsafe use, etc.
• Machinery, plant and equipment failing to perform to the
capacities stated in specifications and instructions for
use.

3. Unsafe clothing.
• Dress or apparel hazards.
• Unavailability of necessary personal protective
equipment.
• Improper and inadequate clothing.

NOTE: The unsafe situation may be more applicable as a latent case.

E.g.If the unsafely clothed person is inactive. If clothed unsafely
during the performance of work however, the unsafe act may be more
applicable than the unsafe condition. I.e.. The behaviour is unsafe.

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 Accident Causation
4. Unsafe workplace.
• General hazards of the workplace that can effect
everyone in the area regardless of assignment.
• Inadequate space and clearance for moving objects.
• Inadequate traffic controls, routing and directives.
• Unsafe or inadequate entrance and exit.
• Poor floor condition.
• Poor maintenance and cleaning of the workplace.
• Improper illumination, poor lighting, shadowing, glare.
• Poor atmosphere control, draft, leaks, ventilation.
• Excessive noise.

5. Hazardous procedures.
• (See unsafe acts)

6. Layout and storage.

• Unsafe position of materials, equipment, tools etc.
• Unsafe stacking/piling.
• Inadequate security.
• Contiguity not considered.
• Containers/packages damaged or vulnerable to damage.

7. Unsafe guarding.
• Unguarded mechanical or physical hazards.
• Inadequate guarding.
• Inadequate shoring or supporting.
• Ungrounded.
• Uninsulated.
• Uncovered connections, switches, fuse boxes.
• Unshielded against radiation, heat, metal spray, UV rays.
• Inadequately shielded.
• Unlabeled or inadequate labelling of materials and
containers.

8. Unsafe outside environment

• Hazards outside the Company premises and beyond
Company’s control.
• Defective materials, tools and equipment of third parties.
• Hazards associated with the property or the operations of
third parties.
• Natural hazards, weather, terrains, animals, lightning

9. Public hazards.
• Public transport.
• Traffic, congestion, hazards.
• Hazards to which everyone may be exposed.

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 Accident Causation
Incident / Contact.
When potential causes of accidents are permitted to exist, the way is always
open for a contact with a source of energy that is above the threshold limit of
the body or structure in question at most risk to the accidental loss that may
likely result.

The incident and contact phase of an accident is thus the event that precedes
the “loss” i.e. the contact that could or indeed does cause the harm
and/or damage to occur.
e.g. If one considers a moving object (say a travelling block or a rotary component)
that involves kinetic energy that is suddenly transferred to the body or structure it hits
or contacts. If the energy transfer is too great, it may cause personal harm or
property damage.

This is not only true of kinetic energy but by all forms, e.g. Acoustic, electrical,
mechanical, thermal, chemical, radiant.

Listed below are some of the more common types of energy transfers that we
are more familiar with in terms of accident causation.

1. Struck against (running or bumping into)

2. Struck by (hit by a moving object)
3. Fall to lower level (either the body falls or the object falls and hit the
body.)
4. Fall on same level (slip and fall, trip over)
5. Caught in (mechanically stuck, pinched, nip points)
6. Caught on (snagged, hung up)
7. Caught between (crushed, sheared, Jammed)
8. Contact with (electricity, heat, pressure, noise, radiation, vibration,
chemicals, noise)
9. Overstressed, fatigued, overexerted, over loaded.

Thus thinking of accident causation in terms of contact and energy exchange

should help to structure thinking about means to control. Control measures
that thus absorb energy can minimise both harm or damage resulting at that
time and at the point of contact. The best oilfield examples of such control
measures to illustrate would be the hard hat and safety glasses. These items
may not prevent contact but can absorb energy to prevent or minimise injury.

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 Accident Causation
Other examples of control and the contact stage are using less harmful
chemicals, reducing the amount of energy released, using a soft torque
system to prevent vibrational energy effects being transmitted to the drillstring
and its components.

When substandard conditions are permitted to exist (such as unguarded tools,

equipment or people), there will always be a potential for contact and energy
exchange that can ultimately result in the harm to people, property, and/or
process

Loss.
Finally the result of an accident is loss. The most obvious being harm to
people, property or process. Other implied and imported related losses are
“performance interruption” and “profit reduction”. So losses involve people,
property, process and profit.

The loss control iceberg depicted in appendix 1 of this document serves to

conclude this document and to illustrate the importance of realising all aspects
to prevent and mitigate against accidental loss.

Any organisation that thus determines the costs of accidents in terms of

compensation and insured costs is looking only at a small fraction of all
identifiable costs, many of these that will come straight out of profit.

The conclusion is simple.

“Save a dollar in accidental loss and you will add a dollar to

profit”.

Can you know understand why management should be more interested in

your safety and accident “loss” causation prevention. It’s a win-win for all, i.e.
your health, safety and welfare and as importantly the profitability or “loss
avoidance” of their business.

Regards,

Peter Aird.
11 April 2001

www.kingdomdrilling.co.uk Wednesday, 11 April 2001

Appendix 1.
Accident or Loss Causation Model

Lack of Basic Immediate Accident

Incident
Control Causes causes (Loss)

1. Inadequate
Contact People
program Personal
with
factors Substandard Property
2. Inadequate acts and
standards conditions
Energy or Process
Job
Substance
3. Non
Factors Production
compliance to
standards

Author: Peter Aird www.kingdomdrilling.co.uk Ref: Accident causation

The loss Control Iceberg

$5-50.
• Facilities damage
• Tools and Equipment damage
• Product and material damage
• Production delays and interruptions
• Legal expenses
• Expenditure of emergency supplies
and equipment
• Interim equipment rentals $1 Compensation
• Loss of reputation
(insured) costs
$3.
• Investigation time
• Wages paid for time lost $5 - $50 uninsured
• Cost of hiring and training
replacements costs
• Overtime
• Extra supervisory time $3 uninsured
• Clerical time miscellaneous costs
• Reduced output
• Loss of business goodwill and

Author: Peter Aird www.kingdomdrilling.co.uk Ref: Accident causation