Diploma - Unit A - Element A2 - March 2011 NEBOSH Diploma in Occupational Licence details RMS Publishing. Victoria House, Lower High Street, Stourbridge DY8 1TA RMS Publishing. Fourth Edition March 2011. All rights reserved. No part of this presentation may be stored in a retrieval system, reproduced, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise without either the prior written permission of the Publishers. This presentation may not be lent, resold, hired out or otherwise disposed of by way of trade in any form other than that in which it is published, without the prior consent of the Publishers. Whilst every effort is made to ensure the completeness and accuracy of the information contained herein, RMS/ACT can bear no liability for any omission or error. Issued to: Single Licence Licence No: DIP Unit A 4th Edition - Element A2 - v.1.0 - Slide 1 DIP Unit A 4th Edition - Element A2 - v.1.0 - Slide 2 NEBOSH Diploma in Occupational Unit A Managing DIP Unit A 4th Edition - Element A2 - v.1.0 - Slide 3 DIP Unit A 4th Edition - Element A2 - v.1.0 - Slide 4 Element A2 Loss causation and incident investigation Learning outcomes A2.1 Explain theories of loss causation A2.2 Explain the quantitative analysis of accident/incident ill-health data, limitations of their application, and their presentation in numerical and graphical form A2.3 Explain the statutory and the internal reporting and recording systems for injuries, ill-health, dangerous occurrences and near-misses A2.4 Explain loss investigations; the requirements, benefits, the procedures, the documentation, and the involvement of and communication with relevant staff and representatives DIP Unit A 4th Edition - Element A2 - v.1.0 - Slide 5 DIP Unit A 4th Edition - Element A2 - v.1.0 - Slide 6 Sample of PowerPoint presentation for NEBOSH Diploma in Occupational 1
Diploma - Unit A - Element A2 - March 2011 Contents A2.1 A2.2 Quantitative analysis of accident and ill-health data A2.3 Reporting and recording of injuries, ill-health, dangerous occurrences and near-misses A2.4 Loss investigations Contents A2.1 A2.2 Quantitative analysis of accident and ill-health data A2.3 Reporting and recording of injuries, ill-health, dangerous occurrences and near-misses A2.4 Loss investigations DIP Unit A 4th Edition - Element A2 - v.1.0 - Slide 7 DIP Unit A 4th Edition - Element A2 - v.1.0 - Slide 8 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 Accident Near miss Source: HSG245. DIP Unit A 4th Edition - Element A2 - v.1.0 - Slide 9 DIP Unit A 4th Edition - Element A2 - v.1.0 - Slide 10 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 DIP Unit A 4th Edition - Element A2 - v.1.0 - Slide 11 DIP Unit A 4th Edition - Element A2 - v.1.0 - Slide 12 Sample of PowerPoint presentation for NEBOSH Diploma in Occupational 2
Diploma - Unit A - Element A2 - March 2011 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. DIP Unit A 4th Edition - Element A2 - v.1.0 - Slide 13 DIP Unit A 4th Edition - Element A2 - v.1.0 - Slide 14 Accident ratio pyramid Source: HSG96 the costs of accidents at work. 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 DIP Unit A 4th Edition - Element A2 - v.1.0 - Slide 15 DIP Unit A 4th Edition - Element A2 - v.1.0 - Slide 16 Limitations Bird s 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 timeframe, 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 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 DIP Unit A 4th Edition - Element A2 - v.1.0 - Slide 17 DIP Unit A 4th Edition - Element A2 - v.1.0 - Slide 18 Sample of PowerPoint presentation for NEBOSH Diploma in Occupational 3
Diploma - Unit A - Element A2 - March 2011 Accident causation domino Further research by the International Loss Control Institute (ILCI) into led them to put forward a modified domino theory Source: H.W. Heinrich. DIP Unit A 4th Edition - Element A2 - v.1.0 - Slide 19 DIP Unit A 4th Edition - Element A2 - v.1.0 - Slide 20 Accident causation domino Loss Event Immediate (direct) causes Underlying (indirect or root) causes - Organisational factors - Job factors - Personal factors Source: Frank Bird - ILCI. DIP Unit A 4th Edition - Element A2 - v.1.0 - Slide 21 DIP Unit A 4th Edition - Element A2 - v.1.0 - Slide 22 Lack of management control Policy Planning Organising Controlling Monitor Review Sequence of dominoes Source: HSG245. DIP Unit A 4th Edition - Element A2 - v.1.0 - Slide 23 DIP Unit A 4th Edition - Element A2 - v.1.0 - Slide 24 Sample of PowerPoint presentation for NEBOSH Diploma in Occupational 4
Diploma - Unit A - Element A2 - March 2011 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 Rasmussen s work in 1987 - called active failures Reason identified three further levels of human failure that comprised latent failures Source: RMS. DIP Unit A 4th Edition - Element A2 - v.1.0 - Slide 25 DIP Unit A 4th Edition - Element A2 - v.1.0 - Slide 26 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, Reason s 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. Reason s accident model Source: Reason/RMS. DIP Unit A 4th Edition - Element A2 - v.1.0 - Slide 27 DIP Unit A 4th Edition - Element A2 - v.1.0 - Slide 28 Part only of the complete Element A2 PowerPoint Presentation DIP Unit A 4th Edition - Element A2 - v.1.0 - Slide 29 Sample of PowerPoint presentation for NEBOSH Diploma in Occupational 5