Accident Investigation and Causation

Determining why accidents occur

Risk and Accidents

Riskdescribes both probability and severity of loss event Risk = Probability x Severity
Probabilitylikelihood of an event taking place
Frequent Probable Occasional Remote Improbable Catastrophic Critical Marginal Negligible

Severity

Types of Risk
Speculative loss exposures
Offer opportunity for gain, as well as loss Marketing and business ventures

Pure loss exposures

Potential for loss with no opportunity for gain Theft, fire, accident

Determining Exposures or Risks

Sometimes outside consultants used Or loss control experts from insurance company Develop priority to do list based on risk assessment Resources and other corporate demands will influence actions

Risk Assessment
Hazard identification - is used to determine the health, ecological, economic, or quality of life effects of a substance, activity, or problem. Exposure assessment - is used to evaluate the routes, media, magnitudes, time and duration of actual or anticipated exposure, and of anticipated exposures, as well as the number of people, species, and/or area exposed. Amount or dose-response assessment - is used to estimate the relationship between the amount of the substance and the incidence of adverse effects. Risk characterization - is used to estimate the probable incidence of an adverse effect under various conditions of exposure, including a description of the uncertainties involved.

Control Techniques for Loss Exposures

Loss Control Techniques
Engineering controls
Reduce level of hazard

Administrative controls
Reduce exposure time to hazard

Personal Protective Equipment (PPE)

Last line of defense Least desirable

Control Techniques for Loss Exposures

Financing Techniques
Avoidancecompany chooses to avoid risk of loss by eliminating chance for liability Substitutionuse of safer materials or processes to accomplish task Transfer of liabilitysubcontract out hazardous tasks Insuranceshifts risk to insurance company Self-insurancereally no insurance, company assumes all risk

Accident Causation Theories

Single Factor Theory
Singular and relatively simple cause for all accidents Overlooks many contributing factors Not recommended

Domino Theories
3 phases
Pre-contact conditions that lead to the accident Contact individual or machine come into contact Post-contact the result of the accident or energy exposure

Represent accidents as predictable, chronological sequences of events or factors

Heinrichs Domino Theory 1920s

5 factors influence all accidents
Negative character traits can be acquired or inherited Negative character traits are why people behave in unsafe manner Unsafe acts are direct cause of accidents Injuries are typically caused by falls and impact of moving objects Typical injuries include lacerations and fractures

Injuries are caused by action of preceding factors Removal of events prior to accident will prevent injury

http://personal.cityu.edu.hk/~meachan/IAA/ analysis/heinrich.html

Bird and Loftus Domino Theory

1976 5 dominos
Lack of control by management Basic causesorigin Immediate causessymptoms Incidentcontact People/property losses

Management is responsible for safety and health of employees

Marcums Domino Theory

7 domino sequence of misactsidents
Inadequate preparation Substandard performance Miscompensated risk Harmful contact incident Adverse reaction Sustained losses Incurred costs

Said accidents are not Acts of God, but have specific causes and are controllable

Multiple Causation Theories

Groses Multiple factors theory
4 Ms
Machine Media Man Management

Attempts to identify workplace characteristics that can reveal underlying causes of accident

Multiple Causation Theories

Firenzies Symptoms Theory of Causation
Based on interaction of man, machine, and environment Countless decisions by operator, each with some likelihood of an accident

Psychological/Behavior Theories
Goals Freedom Alertness Theory
Create positive climate to increase worker alertness

Motivation reward Satisfaction Model

Higher quality work performance is achieved through setting attainable goals Rewards have greatest impact on performance

Human Factors Theory

Accidents are the result of human error and caused by overload, inappropriate activities, and inappropriate response

Energy-related Theories
Accidents are physical engineering problem Result when energy is out of control List of 12 barriers to accident-causing energy

Accident Investigation
Purpose is to determine the causes that resulted in the accident, not fault finding 5 Ws and How?
Who, What, When, Where and Why

Who are the victims? Witnesses? Has pertinent information? What events led up to accident? What activities were victim and witnesses doing prior to and during incident?

More Questions
What are backgrounds of all parties involved? Where were victims and witnesses prior to and during incident? Where was equipment and machinery? Where was PPE, locks and tags? When did incident occur?
Date and time

More Questions
When did you notice problem existed? How did incident take place? How did victims and witnesses react? How did you learn of incident? Why did incident happen? Why were conditions existing at time?

Conducting the Investigation

ASAP to preserve evidence and memories Search key elements
Personnel Equipment Environment Materials

Notify appropriate authorities

OSHA EPA CHEMTRAC