Diploma Unit A - Element A2 - Loss causation and incident investigation

NEBOSH DIPLOMA
IN OCCUPATIONAL HEALTH AND
SAFETY

February 2014

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RMS Publishing.

Unit A

Fifth Edition November 2013.

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Managing health and safety

Issued to:
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ELEMENT A2
LOSS CAUSATION AND INCIDENT
INVESTIGATION

LEARNING OUTCOMES
A2.1
A2.2

A2.3

A2.4

Explain theories of loss causation

Explain the quantitative analysis of accident/incident
ill-health data, limitations of their application, and
their presentation in numerical and graphical form
Explain the statutory and the internal reporting and
recording systems for injuries, ill-health, dangerous
occurrences and near-misses
Explain loss investigations; the requirements,
benefits, the procedures, the documentation, and
the involvement of and communication with relevant
staff and representatives

CONTENTS

CONTENTS

A2.1
A2.2

A2.1
A2.2

A2.3
A2.4

Theories of loss causation

Quantitative analysis of accident and ill-health
data
Reporting and recording of injuries, ill-health,
dangerous occurrences and near-misses
Loss investigations

A2.3
A2.4

Theories of loss causation

Quantitative analysis of accident and ill-health
data
Reporting and recording of injuries, ill-health,
dangerous occurrences and near-misses
Loss investigations

Sample of PowerPoint presentation for NEBOSH National Diploma in Occupational Health and Safety

Diploma Unit A - Element A2 - Loss causation and incident investigation

February 2014

Theories of loss causation

ACCIDENT/NEAR MISS

Theories of loss causation

Losses result from lack of control
Revealed by loss causing events accident
Definition of an accident is:
An unplanned, uncontrolled event which led to, or could
have led to injury to persons, damage to plant or some
other loss to the company
Definition includes near misses', i.e. where no injury or
damage etc. occurs
Important not to think of injuries, damage and other losses
as accidents, but rather as the results of accidents

Accident

Near miss

Source: HSG245.

Theories of loss causation

Theories of loss causation

Difference between a near miss and a fatal accident in

terms of time and distance can be very small
The damage to persons or property is not the accident, but
part of the effects of the accidents (i.e. the result or
consequences).
An old adage says never waste an accident
Every accident constitutes an opportunity to correct some
problem
A near miss which has the potential to cause loss is just as
important as a serious injury/damage

HSG245 Investigating accidents and incidents

An adverse event includes accidents and incidents
The term adverse event, as used by the HSE is similar to
the term accident and encompasses events that have a
wide range of outcomes
The HSE reserve the term accident for events that involve
harm to people
The HSE define an Accident as:
An event that results in injury or ill-health

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Theories of loss causation

Theories of loss causation

ACCIDENT RATIO STUDIES AND THEIR USE

AND LIMITATIONS

ACCIDENT RATIO STUDIES AND THEIR USE

AND LIMITATIONS

Some years ago, a study of 1,750,000 accidents, in 21

industry sectors, led by Frank Bird, showed that there is a
fixed ratio between losses of different severity (and
accidents where no loss occurred, i.e. near misses)
This can be demonstrated with a pyramid model

Accident ratio study

Source: Frank Bird.

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Sample of PowerPoint presentation for NEBOSH National Diploma in Occupational Health and Safety

12

Diploma Unit A - Element A2 - Loss causation and incident investigation

February 2014

Theories of loss causation

Theories of loss causation

ACCIDENT RATIO STUDIES AND THEIR USE

AND LIMITATIONS

ACCIDENT RATIO STUDIES AND THEIR USE

AND LIMITATIONS

Accident ratio pyramid

Use
If only those resulting in injury are considered, many opportunities
to learn about what goes wrong are being missed
If near misses are also studied they can provide more
opportunities to learn and possibly prevent some of the events
that result in injury
The Bird model includes property damage in addition to near
misses
The models help to convince people of the value of reporting a
wide range of events and show that there are usually more near
misses than injury events
Source: HSG96 the costs of accidents at work.

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Theories of loss causation

Theories of loss causation

ACCIDENT RATIO STUDIES AND THEIR USE

AND LIMITATIONS

DOMINO AND MULTI-CAUSALITY THEORIES

Limitations
Birds findings are not uniform throughout industry
The accident ratio studies may not necessarily show the extent of
the loss to the organisation
There are no universally agreed definitions of each subset of
accident type
Statistical analysis of loss events relies on large numbers,
comparable work and worker skills over the measured time-frame, to
be effective
In smaller organisations, the first recorded accident may be the top
event, i.e. fatality or major injury
Near miss reporting may mean different things to different people

HW Heinrich proposed one of the first coherent theories of

accident causation in the mid 1920s
Suggested that accidents were not acts of God but were
caused by the failures of people
His domino theory suggested that the series of events,
which led to an injury or some other loss, were a
succession of events which followed a logical pattern

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Theories of loss causation

Theories of loss causation

DOMINO AND MULTI-CAUSALITY THEORIES

DOMINO AND MULTI-CAUSALITY THEORIES

The domino theory

Accident causation domino

The domino theory

Further research by the International Loss Control Institute
(ILCI) into accident causation led them to put forward a
modified domino theory

Source: H.W. Heinrich.

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Sample of PowerPoint presentation for NEBOSH National Diploma in Occupational Health and Safety

18

Diploma Unit A - Element A2 - Loss causation and incident investigation

February 2014

Theories of loss causation

Theories of loss causation

DOMINO AND MULTI-CAUSALITY THEORIES

DOMINO AND MULTI-CAUSALITY THEORIES

The domino theory

Accident causation domino

Loss
Event
Immediate (direct) causes
Underlying (indirect or root) causes
- Organisational factors
- Job factors
- Personal factors

Source: Frank Bird - ILCI.

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Theories of loss causation

Theories of loss causation

DOMINO AND MULTI-CAUSALITY THEORIES

DOMINO AND MULTI-CAUSALITY THEORIES

Lack of management control

Policy
Planning
Organising
Controlling
Monitor
Review

Sequence of dominoes

Source: HSG245.

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Theories of loss causation

Theories of loss causation

DOMINO AND MULTI-CAUSALITY THEORIES

LATENT AND ACTIVE FAILURES - REASONS

MODEL OF ACCIDENT CAUSATION

Multiple accident causes

Usually more than one causative factor
Each of the multiple causation factors may be seen as one
domino in its own line of dominoes (just as the roots of a
tree branch out)

Reason proposed four levels of human failure, each

influencing the next
The first level that Reason identifies is unsafe acts of
persons, which ultimately lead to the accident
These unsafe acts were considered to relate to the errors,
such as the skill-based slips/lapses and mistakes identified
in Rasmussens work in 1987 - called active failures
Reason identified three further levels of human failure that
comprised latent failures

Source: RMS.

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Sample of PowerPoint presentation for NEBOSH National Diploma in Occupational Health and Safety

24

Diploma Unit A - Element A2 - Loss causation and incident investigation

February 2014

Theories of loss causation

Theories of loss causation

LATENT AND ACTIVE FAILURES - REASONS

MODEL OF ACCIDENT CAUSATION

LATENT AND ACTIVE FAILURES - REASONS

MODEL OF ACCIDENT CAUSATION

The second level of human failure involves preconditions

that lead to unsafe acts taking place
In many instances, these preconditions can be traced back
to instances of unsafe supervision, the third level of
human failure identified by Reason
Importantly, Reasons identified that causation did not stop
at the supervisory level
He recognised that the fourth level, the organisation
itself, can impact on performance at all levels

J. Reasons accident model

Source: Reason/RMS.

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Quantitative analysis of accident and ill-health data

CONTENTS

METHODS OF CALCULATING INJURY RATES

FROM RAW DATA

A2.1
A2.2

Accident frequency rate: number of accidents over time

Accident incident rate: number of accidents compared with
number of people
Accident severity rate: average number of days lost
compared with hours worked
Ill-health prevalence rate: similar to incidence rate but is an
index of ill-health rather than accidents

A2.3
A2.4

Theories of loss causation

Quantitative analysis of accident and ill-health
data
Reporting and recording of injuries, ill-health,
dangerous occurrences and near-misses
Loss investigations

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ELEMENT A2
LOSS CAUSATION AND INCIDENT
INVESTIGATION

Quantitative analysis of accident and ill-health data

METHODS OF CALCULATING INJURY RATES

FROM RAW DATA
These calculations are made from the actual numbers of
accidents, hours worked, numbers employed and days lost
In order for the result to be a meaningful number, a large
multiplier is included in the equation
The injury rates only mean something if they are compared
to other injury rates and are to be used to show trends
May be compared to rates from previous years, to rates
from other departments in the company, to other companies
or to rates in a particular industry

PART ONLY
SAMPLE

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Sample of PowerPoint presentation for NEBOSH National Diploma in Occupational Health and Safety

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