Safetyincident Investigations, 1st Edition

SAFETY INCIDENT
S A F E T Y I N C I D E N T I N V E S T I G AT I O N
I N V E S T I G AT I O N
SAFETY INCIDENT
I N V E S T I G AT I O N
The investigation of safety accidents and incidents is imperative to understand how to
prevent these events in future, and to reduce their human as well as economic impact.
Setting benchmarks for these investigations is a necessary part of standardising safety
measures. Safety Incident Investigation offers readers useful knowledge that will help to
achieve this.
The book defines important terms, describes a few tragedies caused by safety failures
and lists safety organisations, at the outset. It gives legislation relevant to incident inves-
tigation and reporting and explores accident causation theories and accidents and their
effects. It also describes how to conduct an investigation and how to report an accident.
Important features which readers will find particularly useful include:

• learning outcomes and key terms at the beginning of each chapter to guide the
reader through the content
• an informative incident investigation toolkit
• an explanation of how to structure an incident report
• self-assessment questions at the end of each chapter to test the reader’s understand-
ing of the topic.
CHERYL RIELANDER
Safety Management students, managers and business owners, safety officers and safety
practitioners will find this book a valuable resource.
About the author

Cheryl Rielander is a senior lecturer in Safety Management in the Department of
Operations Management at Unisa, with a BTech degree and a Master’s degree in
Safety Management. She is currently working towards her doctoral degree on Safety Risk
Management at Unisa. Rielander has written a number of chapters in a series of Safety
Management textbooks.
www.juta.co.za CHERYL RIELANDER
Safety Incident Investigation.indd 17-19 2017/01/03 8:09 AM

Safety Incident Investigation
Cheryl Rielander
Safety Incident Invest (FINAL).indd 1 2017/01/03 8:15 AM

First published 2016
Juta and Company (Pty) Ltd

PO Box 14373, Lansdowne 7779, Cape Town, South Africa
© 2016 Juta and Company (Pty) Ltd

ISBN 978 1 4851 2110 7 (Print)
ISBN 978 1 4851 2486 3 (WebPDF)
All rights reserved. No part of this publication may be reproduced or transmitted in any
form or by any means, electronic or mechanical, including photocopying, recording, or
any information storage or retrieval system, without prior permission in writing from the
publisher. Subject to any applicable licensing terms and conditions in the case of elec-
tronically supplied publications, a person may engage in fair dealing with a copy of this
publication for his or her personal or private use, or his or her research or private study.
See section 12(1)(a) of the Copyright Act 98 of 1978.
Project manager: Marlene Rose

Editor: Anne-Louise Taylor
Proofreader: Jean Kilroe
Cover designer: Mignon Deacon
Illustrator: Maya Le Maitre
Typesetter: Henry Daniels at Elinye Ithuba
Typeset in 10.5 pt on 13 pt Rotis Serif
The authors and the publisher believe on the strength of due diligence exercised that
this work does not contain any material that is the subject of copyright held by another
person. In the alternative, they believe that any protected pre-existing material that may
be comprised in it has been used with appropriate authority or has been used in circum-
stances that make such use permissible under the law.

Contents
About the author................................................................................................................................... vii
Acronyms and abbreviations............................................................................................................ ix
Chapter 1: Overview of safety incident investigation....................................................... 1
Learning outcomes.................................................................................................................... 1
Key terms....................................................................................................................................... 1
1.1 Introduction................................................................................................................................. 2
1.2 Historical background.............................................................................................................. 2
1.2.1 Milestones................................................................................................................... 3
1.3 Concepts and terminology..................................................................................................... 5
1.3.1 Safe versus unsafe................................................................................................... 5
1.3.2 Harm.............................................................................................................................. 5
1.3.3 Injury............................................................................................................................. 5
1.3.4 Damage ....................................................................................................................... 5
1.3.5 Incident versus accident ....................................................................................... 6
1.3.6 Basic cause.................................................................................................................. 6
1.3.7 Root or immediate cause...................................................................................... 7
1.3.8 Near-miss incident................................................................................................... 7
1.4 South African workforce......................................................................................................... 7
1.5 Incidents and diseases related to improving safety worldwide.............................. 7
1.5.1 Hawks Nest Tunnel disaster................................................................................. 8
1.5.2 Asbestosis.................................................................................................................... 10
1.5.3 Bhopal gas tragedy.................................................................................................. 11
1.6 Safety organisations................................................................................................................. 12
1.6.1 South African Chambers of Mines.................................................................... 13
1.6.2 National Occupational Safety Association (NOSA)..................................... 14
1.6.3 International Register of Certificated Auditors (IRCA)............................. 15
1.6.4 Safety First Association.......................................................................................... 16
1.6.5 Institute of Safety Management (IOSM)........................................................ 17
1.6.6 South African Institute of Occupational Safety and Health (Saiosh)..... 17
1.7 Conclusion.................................................................................................................................... 17
Self-assessment questions..................................................................................................... 18
Chapter 2: Legislation on incident investigation and reporting................................. 19
Key terms....................................................................................................................................... 19

2.1 Introduction................................................................................................................................. 19
2.2 South African legislation........................................................................................................ 21
2.2.1 Occupational Health and Safety Act 85 of 1993 (OHS Act)................... 21
2.2.2 Compensation for Occupational Injuries and Diseases Act 130
of 1993 (COID Act)................................................................................................... 26
2.2.3 Mine Health and Safety Act 29 of 1996 (MHS Act)................................... 28
2.3 Occupational diseases and injuries in South Africa.................................................... 31
2.4 Reporting an occupational injury or disease to the Compensation
Commissioner.............................................................................................................................. 32
2.5 Conclusion.................................................................................................................................... 33
Chapter 3: Accident causation theories.................................................................................... 35
Key terms....................................................................................................................................... 35
3.1 Introduction................................................................................................................................. 35
3.2 Herbert Heinrich’s domino theory ..................................................................................... 36
3.2.1 The five dominoes.................................................................................................... 36
3.2.2 Heinrich’s 10 axioms of industrial safety....................................................... 38
3.2.3 Frank Bird Jr’s updated domino theory .......................................................... 38
3.2.4 Edward Adams’s domino model of accident causation............................ 40
3.2.5 Michael Zabetakis’s updated domino theory ............................................... 41
3.2.6 James Reason’s ‘Swiss cheese’ model.............................................................. 41
3.3 Russell Ferrell’s human factors theory ............................................................................. 42
3.4 Dan Petersen’s accident–incident causation theory................................................... 43
3.5 Systems theory............................................................................................................................ 45
3.5.1 Systems theoretic accident model and processes...................................... 47
3.6 E Scott Geller’s behaviour-based safety theory ........................................................... 48
3.7 Combination theory.................................................................................................................. 49
3.8 Accident causation and management failures.............................................................. 49
3.8.1 Management’s responsibilities and failures.................................................. 49
3.8.2 Supervisors’ responsibilities.................................................................................. 50
3.9 Accident causation theory related to substance abuse............................................. 50
3.10 Conclusion.................................................................................................................................... 50
Chapter 4: Accidents and loss........................................................................................................ 53
Key terms....................................................................................................................................... 53
iv

4.1 Introduction................................................................................................................................. 53
4.2 Definitions of an accident...................................................................................................... 54
4.3 Aspects of an accident ........................................................................................................... 55
4.4 Accident ratio models ............................................................................................................. 57
4.5 Loss caused by accidents ....................................................................................................... 60
4.5.1 Iceberg model............................................................................................................ 61
4.5.2 Bird and Germain’s loss causation model...................................................... 62
4.6 Ethics in safety............................................................................................................................ 66
4.6.1 Defining ethics........................................................................................................... 66
4.6.2 Ethical and safe leadership................................................................................... 67
4.6.3 Guidelines on ethical behaviour for safety professionals........................ 68
4.7 Conclusion.................................................................................................................................... 69
Chapter 5: Incident prevention, investigation and reporting........................................ 71
Key terms....................................................................................................................................... 71
5.1 Introduction................................................................................................................................. 72
5.2 Legal requirements of reporting incidents...................................................................... 72
5.3 Incident prevention................................................................................................................... 73
5.4 Incident investigation.............................................................................................................. 74
5.4.1 Concepts of incident analysis.............................................................................. 75
5.4.2 Common causes of incidents.............................................................................. 76
5.4.3 Why incidents and diseases are not reported.............................................. 78
5.5 Incident investigation.............................................................................................................. 79
Step 1: Data collection........................................................................................................... 81
Step 2: Analysis of information.......................................................................................... 86
Step 3: Identification of risk control measures............................................................ 94
Step 4: Risk control recommendations and action plans........................................ 94
Step 5: Reports and follow-up........................................................................................... 95
5.6 Drafting, developing and presenting an incident report........................................... 100
5.7 Understanding the purpose of an incident report ...................................................... 101
5.8 Understanding the requirements of an incident report ........................................... 102
5.9 Physical structure of an incident report........................................................................... 102
5.10 Conclusion.................................................................................................................................... 102
References.................................................................................................................................................. 105

About the author
Cheryl Rielander is employed at the University of South Africa (Unisa) as a senior lecturer
in safety management in the Department of Operations Management. She was previously
employed by the South African Defence Force. She has been involved in occupational health
and the medical environment for 20 years. Cheryl has completed a national diploma in safety
management and a BTech degree in safety management at Unisa. She has also completed
a Master’s degree in safety management through the Columbia Southern University and is
in the process of obtaining a doctoral degree in the Business Management Department at
Unisa, with a focus on safety risk management. Cheryl is also the author of a number of
chapters in a series of safety management textbooks for Unisa.

Acronyms and abbreviations
ACM Association for Computing Machinery
ANSI American National Standards Institution
BBS Behaviour-based safety
BLS Bureau of Labour Statistics
COID Act Compensation for Occupational Injuries and Diseases Act 130 of 1993
DMR Department of Mineral Resources
DoH Department of Health
DoL Department of Labour
HSA Health and Safety Agency
HSE Health and Safety Executive
IBAS International Ban Asbestos Secretariat
ILO-CIS International Occupational Safety and Health Information Centre of the
International Labor Office
IOSM Institute of Safety Management
IPLOCA International Pipe Line and Offshore Contractors Association
IRCA International Register of Certificated Auditors
MESORFA Mesothelioma Research Foundation of America
MHS Act Mine Health and Safety Act 29 of 1996
MSRS Mine safety rating system
Nedlac National Economic Development and Labour Council
NIOH National Institute for Occupational Health
NIOSH National Institute for Occupational Safety and Health
NOSA National Occupational Safety Association
OFSWA Ontario Forestry Safe Workplace Association
OHASA Southern African Institute for Occupational Hygiene
OHS Occupational health and safety
OHS Act Occupational Health and Safety Act 85 of 1993
OSHA Occupational Safety and Health Administration
PPE Personal protective equipment
ROSPA Royal Society for the Prevention of Accidents
Saiosh South African Institute of Occupational Safety and Health
SAMRASS South African Mines Reportable Accidents Statistical System
SAMTRAC Safety Management Training Course
SANDF South African National Defence Force
SAPS South African Police Service
SAQA South African Qualifications Authority

SASOHN South African Society of Occupational Health Nursing
SASOM South African Society of Occupational Medicine
SMART Specific and simple; Measurable; Achievable and agreed upon; Realistic;
Timescale
STAMP Systems theoretic accident model and processes
Stats SA Statistics South Africa
UCC Union Carbide Corporation
Unisa University of South Africa
WCL Workmen’s compensation claim forms
WHO World Health Organization

Chapter 1
Overview of safety incident investigation
Learning outcomes
After studying this chapter, you should be able to:
• understand the historical background of incidents
• understand concepts and terminology related to:
ww safe versus unsafe
ww harm, injury, damage
ww incident versus accident
ww root cause of accident or incident
ww near-miss incident
• understand various safety tragedies that occurred, namely:
ww Hawks Nest Tunnel tragedy
ww asbestosis
ww Bhopal gas tragedy
• understand the aspects of safety organisations in South Africa, namely:
ww South African Chamber of Mines
ww National Occupational Safety Association (NOSA)
ww International Register of Certificated Auditors (IRCA)
ww Safety First Association
ww Institute of Safety Management (IOSM)
ww South African Institute of Occupational Safety and Health (Saiosh).
Key terms
Accident National Occupational Safety
Asbestos Association (NOSA)
Basic cause Near-miss incident
Damage Root cause
Harm Safe
Incident Safety First Association
Injury Safety organisations
International Register of Certificated Unsafe
Auditors (IRCA)

1.1 Introduction
Accidents are not a new phenomenon, and many of us have either been in an
accident or been involved in some way, whether it has been a car or work-related
accident. Employees are killed annually and there are billions of lost workdays
per year as a result of workplace accidents. The Health and Safety Executive (n.d.)
defines an accident as an ‘event that results in illness or ill health’.
In today’s dynamic and challenging work environment, employees are required
to take precautions against incidents and accidents. The South African workforce is
comprised of approximately 14 million people (Jacobs & Jeebhay n.d.:257). Much
of South Africa’s health and safety legislation has originated from England and
America. The responsibilities of health and safety legislation are governed and
shared among three state departments, namely the Department of Labour (DoL),
the Department of Health (DoH) and the Department of Mineral Resources (DMR).
Occupation-related injuries and diseases are managed by and reported to the
Compensation Commissioner, as stipulated in the Compensation for Occupational
Injuries and Diseases Act 130 of 1993 (COID Act). According to Jacobs & Jeebhay
(n.d.:260), the number of occupational accidents reported in South Africa totalled
242 424 in 1993, representing an accident rate of 33.4% per 1 000 employees. The
Annual Report of the Compensation Fund 2014/2015 presented by the Compensation
Commissioner states that during the period 1 April 2014 to 31 March 2015 a total
of 225 511 claims were received compared to 310 511 for the same period in the
previous year, indicating a difference of 85 000 and thus showing a decline in the
claims received. According to the Compensation Commissioner, this decline could
be attributed to the processes and importing of claims registered on the old system
to the new claims system. According to the Compensations Commissioner, the old
system was unreliable (DoL 2015:22, 24).
In 1990, occupational diseases in South Africa represented 0.05% of compen
sation claims, and diseases caused by asbestos and silicosis represented 77% of
these claims (DoL 2015:25). The number of medical claims as outlined in the annual
report of the Compensation Commissioner was 609 589 in 2014/2015, compared
to 1 817 383 in 2013/2014 and 934 834 in 2012/2013, with a financial value of
R1 461 088 772 in 2014/2015 compared to R2 129 333 441 in 2013/2014.
From the compensation figures above, one can see that South African workers
are by no means immune to industrial incidents and accidents. It is thus essential
that employers and employees learn how to manage dangers in the workplace
proactively, with the aim of preventing serious incidents and injuries and
unnecessary loss of human life and damage to property.
1.2 Historical background

Before we can understand health and safety in today’s context, we need to know
when people became concerned about health and safety and how our understanding
of health and safety led to progress over time. We also need to understand the
concepts of health and safety and the language used to describe health and safety.

Chapter 1: Overview of safety incident investigation
Health and safety was a concern as far back as ancient Egypt, where a set of laws,
known as the Code of Hammurabi, was enacted by King Hammurabi of Babylon
who reigned from 1792 to 1749 bc. The Code of Hammurabi consisted of 282 laws
in which reference was made to injuries and money deducted from the employer
as compensation for injuries. In ancient Greece, Hippocrates, who was born around
the year 460 bc and is now considered the father of contemporary medicine, found
an association between Greek stoneworkers who worked in environments with rock
dust and their subsequent respiratory illnesses. Health and safety was a growing
concern in the Industrial Revolution of the 18th and 19th centuries. This was a
period when rural societies in Europe became urban and industrial, owing to new
machinery and manufacturing processes. Many people were forced to work in
factories in unsafe working conditions.
Historical teachings have often made reference to slavery and the inhumane
actions of employers, which resulted in numerous occupational-related injuries
and diseases, and eventually led to various occupational health and safety-related
developments. One of these developments is the industrial medical service, which
originated from ancient laws such as when Rameses, in an effort to curb the ongoing
diseases, forced slaves to take daily baths and undergo medical examinations around
1500 bc. Another development was the compensation of injured workers under
Sumarian law around 3 500 bc, which extended to the ancient Greeks, Romans and
Arabs. Evidence found in Roman ruins of ventilated houses, aqueducts, sewerage
systems, public baths and latrines relates to the health and safety concerns during
these times (Goetsch 2005:2).
These developments continued to advance. For example, Georgius Agricola
published a book entitled On the Nature of Metals (which is also known by its Latin
name De re metallica) in 1556. The book emphasised the need for ventilation in
mines. Agricola also included illustrations of tools and machines that could be built
to manage the task of ventilating mines.
In 1567, Philippus Aureolus wrote a thesis, entitled ‘On the Miners’ Sickness
and Other Diseases of Miners’, where he correlated mercury exposure to pulmonary
(lung) disease among smelter workers.
Bernardino Ramazzini, who was a professor of medicine and a physician,
published important works on medicine and diseases between 1663 and 1714. He
stressed the importance of the prevention of diseases before treatment. Ramazzini
published a book entitled Diseases of Workers in 1700, which linked the disease
profile of a worker to the working environment. Ramazzini’s works associated
the handling of harmful products to occupational diseases. He also focused on
unnatural body positions and movements (which is related to ergonomics). Much
of Ramazzini’s work is still relevant.
1.2.1 Milestones
As time passed, safety developed and took on a new and significant place in society
and industry specifically. Working conditions have improved since the Industrial

Revolution with the implementation of safety-related legislation, which is aimed at

improving working conditions and the working environment and reducing the cost
of injuries and diseases related to unsafe working conditions.
To understand South African safety history and background, we need to
investigate where safety movements began. As mentioned in Section 1.1, South
Africa’s safety legislation originated from England and America. American safety
legislation can be traced back to England, where the Industrial Revolution took
place and child labour, long working hours and strenuous work were common
and conducted under unhealthy and unsafe conditions (Goetsch 2005:3). Industrial
workers and their families became despondent with the continual outbreaks of
fever and began demanding better working conditions.
As a result of community and public pressure, the American government was
forced to respond, which led to the promulgation of the Health and Morals of
Apprentices Act of 1802 (also known as the Factory Act of 1802). This Act regulated
the working conditions in factories and paved the way for future safety legislation
and government participation in workplace safety. Government factory inspections
commenced in 1833 and the first safety guards were patented in 1868. In 1869, the
Bureau of Labor Statistics (BLS) was established, with the aim to investigate and
report industrial accidents (Goetsch 2005:3).
During the early 1900s, a study was conducted by Frederick Taylor, an American
mechanical engineer, on the efficiency in manufacturing to determine the impact
of various factors on production, efficiency and profitability. Taylor identified a
connection between lost work time and policies and procedures.
The Bureau of Mines in America was established in 1907 to investigate mining
accidents, exposure and the related health effects, and to suggest rectifications
(Goetsch 2005:4).
A turning point in the history of safety occurred in 1908 with the promulgation
of the Federal Employer’s Liability Act in America, which was derived from German
legislation. Goetsch states ‘the common thread among the various early approaches
to workers’ compensation was that they all provided some amount of compensation
for on-the-job injuries regardless of who was at fault’ (2005:4).
Safety awareness gradually increased and improved after World War I, which
ended in 1918. Contractors were expected to ensure a safe workplace after the war.
Between 1918 and 1950, the safety industry identified two critical factors that
affected the safety or productivity of workers. First, there was a positive relation
between safety and quality. Secondly, off-the-job incidents negatively impacted
productivity. During World War II, the call-up of troops meant that many employers
could no longer meet labour demands because of a lack of available skilled, healthy
employees (Goetsch 2005:5).
The promulgation of safety legislation in America occurred in the 1960s, such
as the Contract Work Hours and Safety Standards Act of 1962, the Federal Metal
and Nonmetallic Mine Safety Act of 1966, the Federal Coal Mine Health and Safety
Act of 1969, and many more. This legislation had an impact on the development
of the Occupational Safety and Health Act of 1970 in America, which eventually

led to the development of the Machinery and Occupational Safety Act of 1983 in
America and, finally, the development of the Occupational Health and Safety Act
of 1993 (OHS Act) in South Africa (Goetsch 2005:5).
1.3 Concepts and terminology

It is important that safety professional and accident investigators understand the
concepts and terminology related to occupational safety, incidents, accidents and
occupational diseases.
1.3.1 Safe versus unsafe

First, we should understand the difference between what is safe (that does not threaten
human life, the environment and property) and what is unsafe (that could threaten
human life, the environment and property) (Esterhuyzen & Smit 2014:2). In section 1 of
the OHS Act, ‘safe’ is defined as being ‘free from any hazard’ and a hazard is defined as
‘a source of or exposure to danger’. Danger, on the other hand, is defined as something
or someone that could cause harm, injury, pain or loss (Merriam-Webster n.d.). The
probability that someone could be injured or killed or that an unpleasant event could
occur is thus the opposite to safe. This is because someone may feel threatened and in
danger of harm, injury, pain, loss and even death.
1.3.2 Harm
Harm refers to a physical or mental state of being as a result of being hurt or
feeling less valuable or successful owing to the actions of someone or something
(Merriam-Webster n.d.). Harm, according to Esterhuyzen & Smit (2014:4), could
also be as a result of exposure to a safety risk, resulting in illness. Harm can be
regarded as any type of impact or experience of the human body or mind owing to
any unacceptable exposure to safety risk (Esterhuyzen & Smit 2014:4).
1.3.3 Injury
Injury is referred to as a state of being, act or event that allows someone or
something to feel ill, unhealthy and not in a good condition. Injury can further be
regarded as an action that results in damage (Merriam-Webster n.d.).
1.3.4 Damage
Damage is referred to as the physical harm caused to someone or something owing
to a mistake or wrong action. Damage also includes emotional harm experienced
by an individual (Merriam-Webster n.d.). Damage is caused not only to a person
but also to property, buildings, equipment and more. According to Esterhuyzen
& Smit (2014:4–5), damage can also refer to the interruptions and disruptions of
business processes and/or structures that result in financial loss and could lead to
unsafe conditions that potentially cause harm.

1.3.5 Incident versus accident

An incident is defined in section 24(1) of the OHS Act as an event that arises out of
or in connection with an employee’s activities in the workplace that could result in:
• unconsciousness
• loss of a limb or part of a limb
• injury
• becoming so ill that the employee may die
• permanent or temporary disability
• being unable to work for at least 14 days
• major incident
• spillage of a dangerous substance
• uncontrolled release of a substance under pressure
• machine failure resulting in a fracture, flying, falling or uncontrolled moving
objects
• uncontrolled machinery.
An accident is described as an unforeseen, unplanned, uncontrolled event that
results in harm, injury and damage to people, property, equipment and the
environment (Merriam-Webster n.d.).
According to Van Loggerenberg (2012:19), accidents have different classifications
as outlined in the Unisa study guide for the module ‘Analyse safety incidents’
(PSMP049):
• mishap causing injury or death
• chance happening without any cause
• unexpected wrongdoing
• undesired, unfortunate and unintended occurrence resulting in harm, injury,
damage and loss
• unforeseen and unintended event
• sudden, unplanned, unexpected event occurring in a specific place
• act of God arising out of natural causes, for example a flood, earthquake or
tornado.
1.3.6 Basic cause

Incidents can be caused by a wide range of factors, and regardless of what preventative
measures have been put in place, an incident could occur (ROSPA 2014). The basic
cause of incidents is mainly considered to be related to personal and/or job or system
factors (De Beer & Heyns 2000:19).

1.3.7 Root or immediate cause

The root (immediate) causes of incidents are the acts or conditions that gave rise to
the incidents (ROSPA 2014; Van Loggerenberg 2012:19).
1.3.8 Near-miss incident

A near-miss incident is an event where an incident is likely to occur or has occurred
with no injury, loss or damage. However, if left unattended or uninvestigated, it could
result in a serious injury, fatality, loss and/or damage (Van Loggerenberg 2012:20).
1.4 South African workforce

South African health and safety services have come a long way. Examples of these
professional bodies include the South African Society of Occupational Health
Nursing (SASOHN), South African Society of Occupational Medicine (SASOM),
South African Institute of Occupational Safety and Health (Saiosh) and Southern
African Institute for Occupational Hygiene (OHASA). However, compared to
international safety and health, South African services do not combine their efforts
and are therefore fragmented with numerous gaps (Jacobs & Jeebhay n.d.:257).
The South African workforce constitutes about 14 million employees and, as
mentioned in Section 1.1, health and safety legislation is governed and shared by
three South African government departments, namely:
• Department of Labour (the main governing body) (DoL)
• Department of Health (DoH)
• Department of Mineral Resources (DMR).
South African health services have developed across a vast array of environments,
such as in rural areas and in the mining industry, with the aim of addressing inherently
dangerous work, increased absenteeism, legal requirements, medical surveillance,
driver safety, marine safety, radiation, lead safety, screening of employees for pension
and insurance risks, and unsafe environments. The South African political arena and
trade unions have also played an important role in the development of health and
safety legislation in the country (Jacobs & Jeebhay n.d.:258).
South African occupational health and safety (OHS) service delivery is
determined by the employment ratio, industrial activities, hazards and risks in an
organisation. Employees’ gender, socio-economic status and health requirements
also play a role in regulating OHS service delivery (Jacobs & Jeebhay n.d.:258).
1.5 Incidents and diseases related to improving safety worldwide

Tragedies in the health and safety industry occur daily across the world, resulting
in many fatalities, disabling injuries and lost work hours in all industries. Several
significant incidents may come to mind. However, according to Goetsch (2005:5),
there are three major incidents that were recorded by the health and safety movement
that triggered significant change in the health and safety industry, namely:

• the Hawks Nest Tunnel disaster

• asbestosis
• the Bhopal gas tragedy.
1.5.1 Hawks Nest Tunnel disaster

The Hawks Nest Tunnel disaster, which resulted in miners contracting silicosis, took
place in the 1930s in Gauley Bridge, West Virginia in America. This incident was
recorded as America’s worst industrial disaster (Lucas & Paxton n.d.). The aim was to
construct a hydroelectric plant along a river for a Union Carbide ferrosilicon alloy plant
to boost West Virginia’s economy. This project was conducted in a location that was
excessively steep and during the peak of the Great Depression, which was the longest-
lasting economic downturn in industrialised western countries (Lang n.d.). Employees
were mainly from the south-east of West Virginia and of African-American origin.
An employee working on the tunnel could work a ten-hour shift per day over a
six-day workweek or, if working inside the tunnel, two shifts of three hours each.
A two-hour period was allowed between shifts to allow the dust to settle; however,
this was not enforced and employees usually entered the tunnels at the beginning
of a new shift. There were approximately 45 employees per shift at each end of the
tunnel (Lang n.d.).
This tunnel process involved drilling holes into the rock surface and inserting
dynamite for blasting. The blasted rock debris then had to be removed by a
procedure known as ‘mucking’, which distributed the dust that probably contained
silica dust particles. The removal of rock debris after blasting was regarded as the
most dangerous part of the job. The rock was placed in a transport carrier known
as a ‘dinkey’, which is a small locomotive. This work involved picking up the rocks
and thus direct contact was made with the silica dust particles. The use of gasoline-
powered equipment in the tunnelling process added to the already polluted dusty
environment in the tunnels (Lang n.d.).
According to Lang (n.d.), the timetable for tunnel completion was the following:
• 1930 March Ground-breaking began.
• June Tunnel excavation began.
• 1931 September Tunnel ‘hold through’ was completed 10 months
ahead of schedule.
Employees were paid off and returned home.
• 1931 December Finalisation of tunnel project.
Remaining employees were paid off and returned home.
• 1934 Completion and opening of Hawks Nest Tunnel and Dam.
Employment turnover was high, with 60% of employees working less than two
months, 80% less than six months and 90% less than one year. The average working
period, according to Lang (n.d.), was 15 to 16 weeks. Lang (n.d.) questioned why
the employment period was so short during the Great Depression when jobs were so

scarce but the wages were good. Lucas & Paxton (n.d.) questioned whether the short
employment period was because of the dangerous working conditions.
Several lawsuits were filed in 1932 by affected employees. By the late 1930s,
the increased publicity about the Hawks Nest Tunnel incident made other industrial
establishments aware of the dangers of silica dust particles and how silica affects
the health of human beings (Lucas & Paxton n.d.).
Looking back at the Hawks Nest Tunnel incident, engineers in 1986 asked
whether or not the employer had been aware of the presence of silica at Gauley
Mountain, whether the employer had been aware of the dangers of silica that
were already known in certain industries, whether control measures and protective
devices had been given to employees, why the tunnel had been widened, thus
increasing the danger to employees, and how many employees had died as a direct
result of tunnelling activities, for example a rock cave-in accident (Lang n.d.).
Medical records from the Hawks Nest Tunnel project were never recovered,
making diagnosis and compensation difficult. In addition, the medical doctor at
the time was not familiar with nor trained in detecting or treating silicosis. The
symptoms of silicosis among miners resemble the symptoms of tuberculosis and the
disease was thus misdiagnosed and treated. Although the records are incomplete,
this incident caused approximately 700 deaths. There is no conclusive evidence of
employees linked to silicosis and many gravesites in Gauley Bridge, West Virginia are
unmarked. The number of employees who returned home and developed silicosis was
never determined (Lucas & Paxton n.d.). Silicosis should take an average of 10 to 30
years to present itself as an illness. However, the employees of the Hawks Nest Tunnel
project began dying within a period of one year after exposure. Many families were
not informed of an employee’s death. If families enquired, they were usually told that
the employee had left without indicating where they were going (Goetsch 2005:6–7).
The information received from employees and nearby residents indicated that
employees emerged from the tunnels covered in dust from head to toe and would
leave silica dust footprints along their route home. The employer denied this, stating
that the dust was minimal and that no employee ever complained of the dust. It was
further indicated by the employer that there was no negligence on his behalf and
there was no record of any reported silicosis by an employee. By the mid-1930s, the
court ruling was in favour of compensating the employees. At the time, employee
compensation was determined by race and marital status and ranged from $400 to
$1 000. About $4 million was paid in compensation to affected employees (Lucas &
Paxton n.d.; Lang n.d.). Although this was a disastrous incident, a positive outcome
was that it raised awareness of the dangers of working with silica dust and the
health risks involved (Lucas & Paxton n.d.).
The public exposure to this tragedy led to the establishment of the Air Hygiene
Foundation, which conducts research and develops standards related to workplace
environmental dust. The US Department of Labor provided the resources to list
silicosis as an occupational disease under the Workers’ Compensation Fund in most
states. Millions of employees are still exposed to silica dust, with an average of 250
silica dust-related deaths annually (Goetsch 2005:7).

1.5.2 Asbestosis
There was an increase in the use of asbestos during World War II. Asbestos was
welcomed as a ‘miracle mineral’ because it could be used for almost anything and
was easy to obtain. It was used in construction to strengthen plastic and cement,
and in shipbuilding to insulate boilers and hot water pipes. Car manufactures used
asbestos in brake shoes and clutch pads. It was also used in the production of
ceilings and floor tiles and had many other uses (Cancer Knowledge Base n.d.).
Asbestos, as we know today, is a highly dangerous substance that causes lung
cancer. Asbestos was mined in South Africa and Zimbabwe during the 20th century
and the industry peaked during the late 1970s. Asbestos mining attracted large
economic investment in South Africa, even though its mining industry was
rudimentary and unsophisticated. For example, mining was conducted by farmers
with a spade and wheelbarrow.
According to the Mesothelioma Research Foundation of America (MESORFA n.d.),
asbestos is divided into six types that can be found across the world:
• Chrysotile or white asbestos has a curled fibre and is not easily inhaled and
is thus regarded as a safe asbestos.
• Amosite or brown asbestos originates in Africa, has a needle-like fibre and
was used in industry for numerous reasons, but mainly in cement sheeting
and pipe insulation.
• Crocidolite or blue asbestos also has a needle-like fibre, originates in Africa
and Australia, and is regarded as the most dangerous of all asbestos types.
• Tremolite asbestos is not often used in industry and can be found in limited
amounts in some talcum powders.
• Actinolite asbestos is not often used in industry and can be easily inhaled.
• Anthophyllite asbestos is also not often used in industry.
Asbestos mining in South Africa was unique in the fact that the country mined
three of the principal asbestos types, namely chrysotile or white asbestos, amosite
or brown asbestos, and crocidolite or blue asbestos (Nedlac n.d.).
The World Health Organization (WHO) estimates that approximately 125 million
employees are exposed to asbestos in the workplace worldwide. Inhaled asbestos
fibres may result in a number of lung conditions, such as the commonly known
asbestosis or scarring of the lung tissue. Another is mesothelioma (lung cancer),
which is a cancerous and fatal growth in the lining of the lungs. Both of these
conditions could take 15 to 50 years to present any symptoms and in many cases the
symptoms come at the end stage of the disease, when the prognosis is poor and there
is no possibility of a cure. Many that have been diagnosed with this type of disease
die shortly after diagnosis, owing to the prolonged dormant phase of the disease. In
South Africa, it is said that approximately 200 cases of mesothelioma are reported
annually in the mining industry.
Asbestos eventually became a controlled substance in America from 1970 to
1980, when exposure standards were established and regulated (Goetsch 2005:7).
10

Dr Irving Selikoff established the International Ban Asbestos Secretariat (IBAS) in

1982, which is still the forerunner in fighting asbestos worldwide. In 1983, Iceland
became the first country to ban asbestos use, followed by America in 1999 and
Australia in 2003. Regulations prohibiting the use, processing, manufacturing, and
import and export of asbestos or asbestos-containing materials in South Africa
came into effect in 2008. Today, there are more than 50 countries that have banned
the use of asbestos in totality. It is, however, ironical that America has not totally
banned the use of asbestos, even after all the warnings and publicity. Asbestos is
still found in products in America such as gaskets, roof material, fireproofing and
numerous consumer products used daily (Asbestos.com n.d. 2015).
Senator Patty Murry tried to introduce a Bill in 2002 to ban the use of asbestos
in America, which became known as the ‘Murry Bill’. The Bill was passed in the
Senate in 2007 but was not approved by the House of Representatives. The Murry
Bill aimed at prohibiting the importing, manufacture, processing and distribution
of asbestos-containing products (Asbestos.com n.d. 2015).
Another similar effort was made in America in September 2008 by the Bruce
Vento Ban Asbestos and Prevent Mesothelioma Act, which aimed to amend the
Toxic Substances Control Act of 1976 by revising the definition of asbestos to
include all types of asbestos. To date, no legislation has been passed in America to
ban the use of asbestos (Asbestos.com n.d. 2015).
1.5.3 Bhopal gas tragedy

The Bhopal gas tragedy took place in Bhopal, a city in central India, on 3 December
1984 when methyl isocyanate gas leaked from a nearby industrial plant and killed
5 200 people and incapacitated many more (UCC n.d.). This industrial site was
bordered by a shanty town inhabited by approximately 600 000 people. The
released methyl isocyanate gas remained low on the ground, causing burning eyes
and throats, nausea, vomiting and death. The estimated fatality rate related to the
disaster was originally 3 800 people; however, in 2014 the estimated fatality rate
was estimated at about 16 000 people and it could still increase over time. The
toxins still remain today as clean procedures have not been effectively conducted
and many people exposed to the toxins in 1984 are now giving birth to physically
or mentally disabled children (Taylor 2014).
Findings after the incident indicate that the corrective measures and personal
protective equipment put in place could have prevented this disaster. It was found
that the refrigeration system used to cool down the storage tanks had been switched
off, the scrubbing system used to absorb the vapours had not been available at the
time, and the flare system used to burn away vapours had been non-functional
(Goetsch 2005:7).
An investigation by the International Medical Commissioner shortly after
this tragic incident occurred identified that an additional 50 000 people had
been exposed to the toxic gases. The owner was accused of numerous offences,
including criminal negligence, corporate prejudice and avoidance of safety and
11

health standards enforced by the Occupational Safety and Health Administration

(OSHA). In February 1989, India’s Supreme Court found the owner to be liable and
ordered the payment of $470 million in compensation to the people affected by the
Bhopal incident (Goetsch 2005:7).
It is estimated that thousands of tonnes of the toxic chemical are buried
underground in the region of Bhopal. The area has been proclaimed contaminated
by the government, yet there are no long-term programmes in place to remove the
toxic chemical. Epidemiological research has not proved that the high rate of birth
defects is a result of the spillage that occurred in 1984 (Taylor 2014).
1.6 Safety organisations

As mentioned in Sections 1.1 and 1.2.1, the origins of safety, especially the development
of safety movements and organisations, began in America and England. The Industrial
Revolution aided the efforts to improve workplace safety, which in turn assisted with
the gathering of safety information. This safety information assisted organised safety
movements in North America. For example, Germany published outstanding illustrated
books that dealt with hazards in a wide range of industrial occupations and activities,
and outlined safety control measures (De Beer & Heyns 2000:6–7).
Today, there are various safety organisations worldwide that promote and prevent
safety and health incidents in the workplace (Goetsch 2005:12). According to
Goetsch (2005:12), the following are examples of American organisations that are
concerned with workplace safety abroad:
• American Board of Industrial Hygiene
• American Conference of Governmental Industrial Hygienists
• American Industrial Hygiene Association
• American Insurance Association
• American National Standards Institute
• American Occupational Medical Association
• American Society for Testing and Materials
• American Society of Mechanical Engineers
• American Society of Safety Engineers
• Chemical Transportation Emergency Center
• Human Factors and Ergonomics Society
• International System Safety Society
• National Fire Protection Association
• National Safety Council
• National Safety Management Society
• Society of Automotive Engineers
• Underwriters Laboratories.
12

According to Goetsch (2005:13), the following are examples of American

government agencies concerned with workplace safety abroad:
• Bureau of Labor Statistics
• Bureau of National Affairs
• National Institute of Standards and Technology (formerly National Bureau of
Standards)
• National Institute for Occupational Safety and Health
• Occupational Safety and Health Administration
• Superintendent of Documents, US Government Printing Office
• United States Consumer Product Safety Commission.
• United States Environmental Protection Agency
According to De Beer & Heyns (2000:8–14) South Africa has various organisations
that concentrate on aspects related to safety and health in the workplace, namely:
• Institute of Safety Management (IOSM)
• International Register of Certificated Auditors (IRCA)
• National Occupational Safety Association (NOSA)
• Safety First Association
• South African Chambers of Mines
• South African Institute of Occupational Safety and Health (Saiosh).
1.6.1 South African Chambers of Mines

As with any other organisation, the South African Chamber of Mines has undergone
various changes throughout its history. The Witwatersand Chamber of Mines was
established on 7 December 1887 in a Johannesburg hotel a year after the discovery
of gold on the Langlaagte farm by an Australian gold-digger, George Harrison.
Between 1889 and 1896, the Witwatersrand Chamber of Mines was established
by three founding members with the objective of promoting and protecting mining
interests, promoting public discussion related to the mining industry, promoting
mining legislation and exchanging information with public and private mining
bodies. The Chamber was renamed in 1897 to the Chamber of Mines of the South
African Republic. In 1902, it became known as the Transvaal Chamber of Mines.
However, when the Orange Free State joined the Chamber in 1953, it became
known as the Transvaal and Orange Free State Chamber of Mines. Finally, in 1968,
it underwent another name change to the Chamber of Mines of South Africa, which
is the name we know it as today (Chamber of Mines of South Africa n.d.).
Rand Mutual Insurance Company was established in 1894, with the aim of
insuring mining employees for mining-related injuries in the workplace. During
1913, a team was put together to investigate the high accident fatality rates in
the mining industry. In October 1913, a committee was formed for the prevention
of accidents, which pioneered safety across the world and became known as the
13

Prevention of Accidents Committee. This committee originally concentrated only

on gold mining in the Witwatersrand environment but later included coal and
mineral mining. Today this committee meets under the auspices of the Mine Safety
Division of the Chambers of Mines of South Africa (De Beer & Heyns 2000:8–14).
Legislative requirements for mining were included in the Mines and Works Act
27 of 1956, which has been updated twice: first, by the Minerals Act 50 of 1991
and, secondly, by the Mine Health and Safety Act 29 of 1996 (De Beer & Heyns
2000:8–14).
The Chamber of Mines developed the mine safety rating system (MSRS), which
comprises 16 rating elements and awards a star rating for outstanding safety and
health conduct. The five-star rating system has been designed to assess high-level
implementation and performance in a specified time limit. According to De Beer &
Heyns (2000:8–9), the MSRS elements include:
• leadership and administration
• management training
• planning of inspections
• rules and regulations
• accident investigation
• accident analysis
• emergency preparedness
• care of the injured and ill
• task analysis and procedures
• skills training
• planned task observation
• protective equipment
• programme monitoring
• general promotion
• physical conditions
• compliance with recommended safety practices.
1.6.2 National Occupational Safety Association (NOSA)

The National Occupational Safety Association, better known as NOSA, was
established in 1951 in combination with the Workmen’s Compensation Com
missioner with the objective of preventing occupational accidents and diseases,
eliminating causes of accidents and dealing with concerns related to OHS in South
Africa. The association is well known for its five-star grading system based on
its management of safety objectives developed in the early 1970s. This grading
system can be incorporated in most industries in South Africa and is based on the
principles of:
14

• continual improvement
• commitment and policy
• planning
• implementation and operational control
• monitoring and system review.
The management of safety objectives are grouped into five main categories,
comprising 69 elements. According to De Beer & Heyns (2000:9–10), the five main
categories are:
• premises and housekeeping
• mechanical, electrical and personal safeguarding
• fire protection and prevention
• accident recording and investigation
• health and safety organisation
• environmental control (which was added in 1999).
The association underwent restructuring in 2005. It now falls under MICROmega
Holdings Limited, with the focus on establishing a national OHS service in South
Africa. The association offers a holistic auditing service based on more than 60
years’ experience, which includes legal compliance audits, integrated health, and
occupational health, safety and environmental risk management services in South
Africa. To date, the association provides the NOSA five-star grading system and the
SAMTRAC course as well as NOSA certification. NOSA Africa offers certification
in the following standards: ISO 9001 (quality management system), ISO 14001
(environmental management system) and OHSAS 18001 (OHS management system,
which is expected to be replaced by the ISO 45001 in 2017) (NOSA 2016).
1.6.3 International Register of Certificated Auditors (IRCA)

The International Register of Certificated Auditors, better known in South Africa
as IRCA, is a professional body established for management system auditors. It
was established in 1984 by the British government to create business competition
through the implementation of quality practices and principles. It became a division
of the Chartered Quality Institution, which aims to improve business by enhancing
customer satisfaction, intensifying innovative work methods, increasing efficiency,
reducing cost and waste, identifying risks and reflecting on corporate responsibility
(IRCA 2016).
This professional body developed an audit management system referred to as
the IRCA CAPTM for the implementation of an incident prevention system to detect
and correct system failures. This system comprises 15 elements that are used after
an accident to control the health, safety, environment and quality-related risks
that had caused the accident. According to De Beer & Heyns (2000:11–12) the core
elements related to the IRCA CAPTM are:
15

• planning and leadership

• training and communication
• job and operational analysis
• change management
• purchasing systems
• work rules and operating permits
• inspections
• occupational health and hygiene systems
• personal protective equipment
• incident investigation and analysis
• emergency preparedness
• audits and reviews
• corrective and preventative action systems
• environmental management systems
• quality management systems.
According to De Beer & Heyns (2000:12), additional operational aspects that could
be added to the IRCA CAPTM are:
• hazard identification and risk assessment
• cultural behavioural modelling
• security management
• fire protection
• product stewardship
• seismicity
• fleet management.
1.6.4 Safety First Association

The Safety First Association is the oldest OHS association in South Africa and was
established in 1932 by Sir Ernest Oppenheimer and the mayor of Johannesburg.
Oppenheimer identified the necessity for stricter safety laws in the mining industry
as mine workers were frequently injured at work, often with fatal consequences.
The Safety First Association supported Oppenheimer’s efforts and continues to
support the role of safety education in South Africa. This supportive role was
achieved by publishing a safety magazine known as Safety First, which was later
renamed Industrial Safety and then National Safety (Safety First Association 2016).
The Safety First Association has continued to support the growth of safety
in South Africa, together with world events related to safety. In the past, the
association reported on industrial problems experienced during World War II as
well as the aftermath of the war, specifically on how to deal with disabled soldiers
in the workplace. With the introduction of television in South Africa in 1975,
16

the Safety First Association dedicated an entire magazine issue to the dangers of
televisions (Safety First Association 2016).
The Safety First Association has also concerned itself with safety conferences
and exhibitions. The first conference was held in Durban in 1937. In 1938, a safety
week was announced and in 1975, the Safety First Association was instrumental in
organising the ‘Keep alive in 75’ exhibition in Sandton City, Johannesburg. The Safety
First Association regularly holds conferences with partners, which creates a networking
opportunity for all industries in South Africa (Safety First Association 2016).
1.6.5 Institute of Safety Management (IOSM)

The Institute of Safety Management, better known as IOSM, is committed to
improving the professional skills of safety professionals in South Africa (IOSM
n.d.). It aims to promote the ‘art and science of accident prevention and loss control’
(De Beer & Heyns 2000:13).
The IOSM members come from a wide selection of disciplines and professions
including, occupational hygiene, occupational health, occupational medicine, fire
protection services, risk management, ergonomics and many more (De Beer &
Heyns 2000:13).
The IOSM has various branches established across South Africa and currently
there are branches in Johannesburg, Pretoria, Durban, Cape Town, Port Elizabeth,
Polokwane, Pietermaritzburg, East London and Bloemfontein. Membership is open to
any person subscribing to the aims and objectives of IOSM (De Beer & Heyns 2000:13).
1.6.6 South African Institute of Occupational Safety and Health (Saiosh)

The South African Institute of Occupational Safety and Health (Saiosh) was
established when South Africa celebrated the 20th anniversary of the release of
Nelson Mandela from prison on 11 February 2010. The institute has over 6 000
members from a wide range of industries and is the principal source of health and
safety networking in South Africa (Saiosh n.d.).
The South African Qualifications Authority (SAQA) acknowledges Saiosh as
a professional body for the registration of OHS professionals in South Africa.
The institute is governed by its construction, code of conduct and disciplinary
procedures. The objectives of Saiosh are to prevent and reduce incidents in the
workplace by promoting OHS practices in South Africa (Saiosh n.d.).
1.7 Conclusion
Safety is not a new concern. It dates back as far as ancient Egypt, the Roman Empire
and the Industrial Revolution. Studies related to specific occupational diseases were
conducted by numerous people. Published manuscripts on specific diseases related
to certain environments. An example is On the Nature of Metals (De re metallica),
which was published in 1556 and outlined the importance of ventilation.
17

During the Industrial Revolution, safety legislation was developed because of child
labour, the long working hours and the appalling working conditions. Looking at
some of the tragedies experienced across the world, one wonders why these events
had to occur before action was taken. However, gradually these accidents and
incidents led to the development of safety legislation and safety organisations as
we know them today.
Self-assessment questions
1. Briefly explain the historical background of safety and mention the significant
safety incidents that were discussed in this chapter.
2. Explain the following concepts and terms:
(a) safe versus unsafe
(b) harm versus injury
(c) incident versus accident
(d) root cause of an accident or incident
(e) near-miss incident.
3. Explain in your own words what happened to the workers in the Hawks Nest
Tunnel disaster.
4. Explain in your own words the dangers of asbestos in the workplace.
5. Explain in your own words what happened during the Bhopal gas tragedy.
6. Discuss how the following safety organisations address aspects of safety in
South Africa:
(a) South African Chamber of Mines
(b) National Occupational Safety Association (NOSA)
(c) International Register of Certificated Auditors (IRCA)
(d) Safety First Association
(e) Institute of Safety Management (IOSM)
(f) South African Institute of Occupational Safety and Health (Saiosh).
18

Chapter 2
Legislation on incident investigation and reporting
Learning outcomes
• understand the development of safety legislation on incident investigation and
reporting
• understand the South African safety legislation on incident investigation and
reporting
• understand the process of reporting occupational injuries and diseases relating
to the Occupational Health and Safety Act 85 of 1993 (OHS Act)
• understand the process of reporting occupational injuries and diseases relating to
the Compensation for Occupational Injuries and Diseases 130 of 1993 (COID Act)
and the workmen’s compensation claim (WCL) forms.
Key terms
Annexure 1: Recording and Occupational diseases
investigation of incidents Occupational Health and Safety Act 85
Compensation for Occupational Injuries of 1993, sections 24 and 25
and Diseases Act 130 of 1993 Workmen’s compensation claim (WCL)
Mine Health and Safety Act 29 of 1996 forms
2.1 Introduction
Safety legislation is by no means new to society. As previously discussed in Chapter
1, Section 1.1, the Code of Hammurabi, a set of laws enacted by King Hammurabi
of Babylon dating back to about 1754 bc, reflects a concern for injury management
as a result of unsafe working conditions. During the Industrial Revolution, interest
in safety grew among the gentry as they became concerned with the number of
occupational injuries and deaths. These interests led to the development of writings
and reports that were eventually enacted in law.
The Health and Morals of Apprentices Act 1802, which is also known as
the Factory Act 1802, was an Act of Parliament in the United Kingdom. It was
introduced by Sir Robert Peel, who was influenced by Dr Thomas Percival’s report
on occupational health. The Factory Act 1802 stipulated working hours of no more
than 12 hours a day and proper ventilation, among other requirements. According
to Goetsch (2005:6), the Factory Act 1802 paved the way for the development of
the following legislation in the USA:

• 1833 Factory Bill becomes the Factory Act and the role of a factory
inspector is created.
• 1864 Mine Safety Act in Pennsylvania is passed and the first accident
insurance policy is issued in North America.
• 1867 First government-sponsored factory inspection programme is
established.
• 1868 First safety guard is patented.
• 1877 Law is passed for guarding hazardous machinery.
• 1892 First safety programme is launched.
• 1895 Compulsory notification of industrial diseases in the workplace.
• 1898 Appointment of the first factory inspector.
• 1902 First workers’ compensation law is passed in Maryland.
• 1907 The United States Bureau of Mines is established.
• 1908 Development of the first workers’ compensation law.
• 1911 Workers’ compensation law is passed in Wisconsin.
• 1913 National Council of Industrial Safety is established.
• 1915 National Council of Industrial Safety undergoes a name change to
the National Safety Council.
• 1918 Founding of the American Standard Association, known today as the
American National Standards Institution (ANSI).
• 1936 A call was made for a federal occupational safety and health law,
which was implemented 58 years later.
• 1952 Federal Coal Mine Safety Act is promulgated.
• 1966 Metal and Nonmetallic Mine Safety Act is promulgated.
• 1968 Another call is made for a federal occupational safety and health law
by President Johnson.
• 1969 Construction Safety Act is promulgated.
• 1970 Occupational Safety and Health Act is approved by President Nixon,
which leads to the establishment of the Occupational Safety and
Health Administration (OSHA) and the National Institute for
Occupational Safety and Health (NIOSH).
• 1977 Federal Mine Safety and Health Act is promulgated.
• 1983 Machinery and Occupational Safety Act is promulgated.
• 1986 Superfund Amendments and Reauthorization Act is promulgated.
• 1990 Clean Air Act is promulgated.
• 1993 The concept of Total Safety Management is introduced.
• 2000 The USA begins to investigate the promulgation of ISO 14000
registration on environmental management.
20

Chapter 2: Legislation on incident investigation and reporting
2.2 South African legislation

As discussed in Chapter 1, much of South Africa’s health and safety legislation
originated from England and the USA and has been adapted for South Africa. South
African health and safety legislation is shared among three state departments, namely
the Department of Labour (DoL), the Department of Health (DoH) and the Department
of Mineral Resources (DMR). The ‘White Paper for the transformation of the health
system in South Africa’ stated that employers are required to fund the occupational
health services of employees. This paper identified a need to improve occupational
health legislation in South Africa and bring it in line with the International Labour
Organisation (ILO) Conventions, a list of 190 laws that aim to improve the labour
standards of people around the world (Jacobs & Jeebhay n.d.:257).
Two occupational health services regulatory professional associations in South
Africa are the South African Society of Occupational Medicine (SASOM) and the
Health and Safety Agency (HSA). According to Jacobs & Jeebhay (n.d.:265), there
appears to be no consensus by the state on the regulation of occupational health
services. Presently only large companies, concentrating mainly in urban areas, are
supplying employees with occupational health services.
South African legislation relevant to workplace incidents and accidents includes the:
• Compensation for Occupational Injuries and Diseases Act 130 of 1993 (COID Act)
• Occupational Health and Safety Act 85 of 1993 (OHS Act)
• Mine Health and Safety Act 29 of 1996 (MHS Act).
For the purpose of this discussion, we will concentrate on the OHS Act and the COID
Act. However, a person working in a specific industry, such as mining, aviation or
shipping, must consult the relevant legislation when and where it is required.
2.2.1 Occupational Health and Safety Act 85 of 1993 (OHS Act)

The Occupational Health and Safety Act 85 of 1993 aims to improve the health and
safety of people in the workplace in South Africa.
Section 8: General duties of employers to their employees

Section 8 of the OHS Act clearly stipulates that an employer must eliminate or
mitigate the hazards and risks to the health and safety of employees and must
implement precautionary measures in the workplace to ensure the employees’
health and safety ‘as far as reasonably practicable’.
Section 24: Report to inspector regarding certain incidents

Section 24 of the OHS Act relates to the reporting of incidents to the chief inspector,
who is appointed by the DoL. Section 24 of the OHS Act requires that an incident
that occurs in the workplace and arises from or in connection with workplace
activities must be reported within the allocated time frames and in the prescribed
manner. According to section 24(1), incidents that should be reported to the DoL
include the following:
21

• if an employee:
ww loses consciousness
ww loses a limb or part of a limb
ww becomes so injured or ill that it could result in a permanent physical
disability or death
ww is unable to commence work activities for 14 days or more
• if a major incident takes place
• if the health and/or safety of any person is compromised
• if spillage of a dangerous substance occurs
• if the uncontrolled release of any substance under pressure occurs
• if a machine or a part of the machine fails, which could lead to flying, falling
or uncontrolled moving objects
• if a machine runs out of control.
Section 24(2) of the OHS Act prescribes that in an event where a person could die,
an incident results in an amputation (partial or total) or the person dies as a result
of the incident, the incident scene may not be disturbed nor may anything be
removed from the scene until approved by the chief inspector. The OHS Act states
that the only actions allowed are to rescue people from danger, remove the injured
for medical assistance and to make the scene safe to prevent further incidents and/
or injury.
Section 24(3) of the OHS Act states that the above-mentioned requirements do not
apply to:
• traffic accidents on a public road
• incidents in private households (provided that they are reported to the South
African police)
• incidents investigated under section 12 of the Aviation Act.
Section 25: Report to chief inspector regarding occupational disease

The Workmen’s Compensation Act 30 of 1941 provides for the compensation of
persons who sustain occupational injuries or diseases or die as a result of these
occupational injuries or diseases.
Section 25 of the OHS Act relates to the diagnosis of an occupational injury or
disease by a medical practitioner, who is compelled by the Workmen’s Compensation
Act to report the injury or disease to the chief inspector in the stipulated period of
time and prescribed manner.
General Administrative Regulations

The General Administrative Regulations determine the administrative procedures
of the OHS Act.
22

Regulation 8: Reporting of occupational incidents and diseases

According to regulation 8(1) and (2) of the General Administrative Regulations, the
provincial director of the DoL must be informed if:
• the incident or disease led to the death of a person or persons
• a person died after the incident or disease was reported.
Regulation 8(1) outlines the OHS Act requirements for reporting occupational
incidents and/or diseases, whereby an occupational incident should be reported
within seven days, using the workmen’s compensation claims documentation, the
WCL1 form titled ‘Employer’s report of an occupational disease’ or WCL2 form
titled ‘Employer’s report of an accident’. If a person dies, becomes unconscious,
suffers the loss of a limb or a part of a limb, is injured or becomes so ill that they
are likely to die or suffer a permanent physical disability, including any other
incident referred to in section 24(1)(b) and (c) of the OHS Act, the incident must be
reported to the provincial director of the DoL.
In the event of the death of an injured person after notice of the incident has
been submitted, the employer must notify the provincial director of the DoL of the
person’s death (regulation 8(2)).
Where incidents occur as a result of an employee’s working environment or as
a result of activities related to or in connection with an employee’s working
environment, regulation 8(3) states that provincial director of the DoL should be
notified of the following:
• name of the injured person
• address of the injured person
• name of the user, employer or self-employed person
• address of the user, employer or self-employed person
• telephone number of the user, employer or self-employed person
• name of contact person
• details of incident:
ww what happened
ww where it happened (place)
ww when it happened (date and time)
ww how it happened
ww why it happened
• the names of witnesses.
In the event of diagnosing an occupational disease, the medical practitioner should
report the occupational disease as referred to in section 25 of the OHS Act within
14 days of examination and diagnosis (regulation 8(4)). The medical practitioner
is required to give notice to the chief inspector of the DoL as well as the person’s
employer, using the WCL 22 form titled ‘First medical report in respect of an
occupational disease’.
23

Regulation 9: Recording and investigation of incidents

Regulation 9 of the General Administrative Regulations outlines the recording and
investigation of an incident, which require the completion of Annexure 1 to the
General Administrative Regulations. The form is titled ‘Recording and investigation
of incidents’ and is shown in Figure 2.1. This form must be kept in safe storage for
a minimum of three years. Regulation 9 requires that the employer investigates all
reportable incidents within seven days of the incident occurring.
ANNEXURE 1
OCCUPATIONAL HEALTH AND SAFETY ACT, 1993 (ACT 85 OF 1993)
REGULATION 9 OF THE GENERAL ADMINISTRATIVE REGULATIONS
RECORDING AND INVESTIGATION OF INCIDENTS
A. RECORDING OF INCIDENT
1. Name of employer
2. Name of affected person
3. Identity number of affected person
4. Date of incident 5. Time of incident
Head or
Neck Eye Trunk Finger Hand
6. Part of body
affected Arm Foot Leg Internal Multiple
Sprains Contusion or
or strains wounds Fractures Burns Amputation
Electric Occupational
7. Effect on person shock Asphyxiation Unconsciousness Poisoning disease
8. Expected period 0–13 2–4 > 4–16 > 16–52 > 52 weeks or
of disablement days weeks weeks weeks permanent disablement Killed
9. Description of Occupational disease**
10. Machine/process involved/type of work performed/exposure
11. Was the incident reported to the Compensation * Make a cross in the
Commissioner and Provincial Director?* YES NO appropriate square
12. Was the incident reported to the SAPS? (In case of a fatal accident)
13. SAPS office and reference
** In case of a hazardous chemical substance, indicate substance exposed to.

➠
24

B. INVESTIGATION OF THE ABOVE INCIDENT BY A PERSON DESIGNATED THERETO

1. Name of investigator 2. Date of investigation
3. Designation of investigator
4. Short description of incident
5. Suspected cause of incident
6. Recommended steps to prevent a recurrence
................................................................... .............................................
Signature of investigator Date
C. ACTION TAKEN BY EMPLOYER TO PREVENT THE RECURRENCE OF A SIMILAR INCIDENT
................................................................... .............................................
Signature of employer Date
D. REMARKS BY HEALTH AND SAFETY COMMITTEE
Remarks
......................................................................................................................... .............................................
Signature of chairperson of the Health and Safety Committee Date
Figure 2.1: Annexure 1 – Recording and investigation of incidents

Source: OHS Act, General Adminstrative Regulations (2003)
25

2.2.2 Compensation for Occupational Injuries and Diseases Act 130 of 1993
(COID Act)
General
The Compensation for Occupational Injuries and Diseases Act 130 of 1993 (COID Act)
provides ‘compensation for disablement caused by occupational injuries or diseases
sustained or contracted by employees in the course of their employment, or for death
resulting from such injuries or diseases’ (COID Act 1993).
The COID Act was established for the compensation of occupational-related
injuries and diseases resulting from partial, total and permanent disabilities during
the course of employment. During the financial period of 2014/2015, the number
of registered and processed claims by the Compensation Commissioner totalled
225 511 compared to 309 065 during the 2013/2014 reporting period (DoL 2015:21).
The COID Act applies to all types of employees from casual to full-time workers and
includes the aviation and maritime industry. However, the Act excludes:
• employees who have been totally or partially disabled for a period of less
than three days
• domestic employees
• members of the South African National Defence Force (SANDF), in other
words, military employees or soldiers
• members of the South African Police Service (SAPS)
• people employed outside South Africa for a period of 12 months or more
• people employed temporarily in South Africa.
The COID Act pays compensation to employees or their dependants when:
• an employee’s death was a result of an occupational injury or disease
• an employee has a temporary disability, meaning the employee is unable to
conduct work activities as employed for a specific period of time owing to an
occupational injury or disease but recovery is expected. Temporary disability
is classified as:
ww partial disability, for example an inability to use a limb for a period of
time such as when a person has a bone fracture
ww total disability, for example unconsciousness
• an employee has a permanent disability, meaning the employee is unable
to conduct work activities as employed owing to an occupational injury or
disease.
Funeral expenses of an employee are covered to the actual funeral cost or the
maximum amount in place at the time, whichever is the lesser amount.
The COID Act requires an employee to report an occupational injury or disease as
soon as possible, preferably within the same shift, but not later than seven days after
the incident has happened. However, the Compensation Commissioner recognises that
there may be problems with reporting and thus allows leniency for up to 12 months
26

after an injury or disease for notification. No occupational injury or disease will be

accepted by the Compensation Commissioner after the 12-month period.
Section 38: Notice of accident by employee to employer

Section 38 of the COID Act states that employees are required to notify their
employer of an accident, either verbally or in writing. The accident must be reported
as soon as possible after it has occurred.
Section 39: Notice of accident by employer to commissioner

Section 39(1) of the COID Act requires that an employer must report an accident to
the commissioner within seven days from having received notice of the accident.
Schedule 2 of the COID Act outlines the type of injuries for which the Compen
sation Commissioner will pay compensation.
Section 65: Compensation for occupational diseases

Section 65 of the COID Act relates to the reporting of an occupational disease for
compensation. The commencement of the disease is from the date on which the
medical practitioner diagnosed the disease for the first time or an earlier date if the
Director-General determines it is in the favour of the employee.
Schedule 3 of the COID Act outlines the diseases for which the Compensation
Commissioner will pay compensation.
Section 68: Notice of occupational disease by employee and employer

Section 68 of the COID Act states that an employee must inform their employer
in writing as soon as possible after diagnosis of the occupational disease. The
employer, in turn, must report this occupational disease within 14 days to the
Compensation Commissioner. The employer must, however, consider the factor of
confidentiality.
Workmen’s compensation forms

The COID Act process is complex and is not discussed in detail in this book. It is,
however, important to outline some of the COID Act documentation that is used in
these processes.
The WCL documentation listed in Table 2.1 is important when reporting an
occupational injury or disease. Please note that these may not be the only WCL
documents required but are those required at the onset of reporting.
27

Table 2.1: Workmen’s compensation forms for occupational injuries and diseases
Occupational injury
WCL number Description
WCL 2 Employer’s report of an accident
WCL 4 First medical report in respect of an accident
WCL 5 Final/progress medical report in respect of an accident
WCL 6 Resumption report
Occupational disease
WCL number Description
WCL 1 Employer’s report of an occupational disease
WCL 22 First medical report in respect of an occupational disease
WCL 26 Progress/final report in respect of an occupational disease
WCL 6 Resumption report
WCL 111 Medical report of a specialist

(Note: Extra information is required in cases of silicosis, asbestosis and
other fibrosis of lungs caused by mineral dust.)
Useful links
The following documents can be downloaded from the DoL website:
WCL forms
Compensation for occupational injuries and diseases forms and sample documents:
http://www.labour.gov.za/DOL/documents/forms/compensation-for-occupational-
injuries-and-diseases/o-forms-and-sample-documents
Useful documents
http://www.labour.gov.za/DOL/documents/useful-documents/compensation-for-
occupational-injuries-and-diseases/useful-documents
2.2.3 Mine Health and Safety Act 29 of 1996 (MHS Act)

It is estimated that about 10% of the world’s gold resources and 40% of other
resources are mined in South Africa, and that there are approximately 36 000
tonnes of unmined resources. It is estimated that approximately two-thirds of the
world’s gold remains unmined (DMR 2011). In South Africa, mining activities are
28

governed by the MHS Act, which aims to provide for the health and safety of
employees in the mining industry (DMR 2011).
The aim of the Mine Health and Safety Inspectorate is to establish a safe and
healthy mining industry and reduce mining-related injuries, diseases and deaths by
formulating and incorporating national mining legislation and policy. According
to the Department of Mineral Resources (DMR 2011:142), the strategic objectives
and activities of the inspectorate are:
• active contribution to sustainable development and growth
• minerals sector regulation
• promoting health and safety
• effective and efficient service delivery
• financial stewardship.
Regulation 23: Reporting of accidents and dangerous occurrences

Regulation 23.1 of the MHS Act states that an owner of a mine must report mine
accidents or any other dangerous incident or incidents to the Mine Health and
Safety Inspectorate of the DMR. According to regulation 23.1, the following
accidents must be reported:
• an injury to an employee that could be or was fatal
• unconsciousness of a person owing to:
ww heatstroke or heat exhaustion
ww insufficient oxygen supply
ww inhalation of poisonous gases, fumes or vapours, and/or
ww electrical shock or burns
• an incident that caused the employee to be incapacitated from the workplace
for 14 days or more
• an incident that caused a total, partial or permanent disability to the
employee
• an injury resulting in the incapacitation of an employee on the next day
after the accident.
A mining injury where a miner is injured, becomes unconscious or is incapacitated
for 14 days or more must be reported immediately to the Mine Health and Safety
Inspectorate of the DMR.
According to regulation 23.2, an accident that resulted in an employee being
incapacitated for 14 days or a total, partial or permanent disability must be reported
within three days to the Mine Health and Safety Inspectorate of the DMR by
completing the following two South African Mines Reportable Accidents Statistical
System (SAMRASS) forms:
• SAMRASS 1 titled ‘Accident and dangerous occurrence report form’
• SAMRASS 2 titled ‘Injury report’.
29

According to regulation 23.2, an accident that results in an injury to an employee

where they were incapacitated for one day must be reported without interruption
each month to the Health and Safety Inspectorate of the DMR by completing the
following form:
• SAMRASS 4 titled ‘1–3 Day injuries’.
Regulation 23.4 of the MHS Act stipulates the following as dangerous occurrences
that must be reported as quickly as possible by submitting the SAMRASS 1 form:
• severe damage to the working environment as a result of a rockburst or fall
of ground
• uncontrolled and unplanned cave-ins, a side wall or slope failure, or
subsistence in the ground that causes damage to the surface, with potential
risk to the safety of miners
• flow of water, broken rock, mud or slimes that could result in potential risks
to the safety of miners, whether controlled or uncontrolled
• breakdown of main ventilation fan
• underground power failures that could result in potential risk to the safety of
miners
• fires, ignitions or explosions relating to mining activities, inclusive of
spontaneous combustion at or in a mine
• discovery of flammable gases that exceed one comma four parts per hundred
by volume in the mine atmosphere or part of it
• failure to control a mine winding plant
• driven or operating machinery of lifts and elevators that has failed or
fractured
• any object falling down a shaft that warrants inspection
• any emergency or rescue procedure, for example breathing apparatus failure
or rescuing trapped miners
• self-propelled mobile machines running out of control that could result in
potential risks to the safety of miners
• failure or fracture of boilers or the safety devices of a boiler or a pressure
vessel that could result in potential risks to the safety of miners
• failure of fracture of any part of safety device of a chairlift
• ignition of explosives, whether accidental or unauthorised.
Note that the above-mentioned list is not comprehensive and the MHS Act must be
referred to for detailed information when submitting the SAMRASS 1 form.
Regulation 23.7 requires mine owners to maintain records of all mine-related
accidents and dangerous occurrences. These records must be safely stored for a
period of two years from the date of the incident and must contain full details of
the incident, accident and/or dangerous occurrence.
30

Useful link
The following documents can be downloaded from the DMR website:
SAMRASS forms
http://www.dmr.gov.za/samrass-forms.html
2.3 Occupational diseases and injuries in South Africa

Statistics regarding occupational diseases and injuries in South Africa are
inaccurate, mainly owing to the fact that industries do not report them, especially
the private industry. Statistics captured by Statistics South Africa (Stats SA 2015)
are mainly from government industries and surveillance programmes linked to
specific occupational diseases and clinic attendance. Occupational disease diagnosis,
according to Stats SA (2015), does not indicate accurate statistics within specific
industries, and statistics are outdated or skewed as a result of reporting bias.
Occupational diseases and injuries are managed by the Compensation Commissioner
and the DoL. According to Jacobs & Jeebhay (n.d.), the most commonly reported
occupational diseases in South Africa are:
• asbestosis
• bronchopulmonary disease
• bronchospasms
• chemical-induced bronchitis
• chronic obstructive airway diseases
• dermatitis
• hepatitis
• lung fibrosis
• mesothelioma
• muscular tendon overstraining
• nasal septum perforation
• noise-induced hearing loss
• occupational asthma
• pleural thickening
• pneumoconiosis
• post-traumatic stress
• Raynaud’s syndrome (hand–arm vibration syndrome)
• silicosis
• tendonitis
• tuberculosis.
31

2.4 Reporting an occupational injury or disease to the Compensation

Commissioner
As previously indicated, the COID Act requires an occupational injury or disease to
be reported as soon as possible, preferably within the same shift, but not later than
seven days after the incident. The COID Act requires that all claims be submitted
electronically as follows:
• An incident resulting in a personal injury for which medical treatment is
required is reported to the Compensation Commissioner by completing the
workmen’s compensation claim form WCL 2 form titled ‘Notice of accident
and claim for compensation’. It is the employer’s responsibility to ensure
that the required WCL documentation is submitted to the Compensation
Commissioner within seven days of the incident. It is regarded as an offence if
an injury is not reported, even if the alleged injury is suspected of being false.
• Claims are submitted online, either by an organisational representative from
an institution or the medical practitioner. Claims are registered and submitted
using the DoL online submission portal.
Useful link
Department of Labour online submission portal:
https://cfonline.labour.gov.za/OnlineSubmissions/;jsessionid=41CCB905C65FE77B9
DF8CC9B5B206744.CFONLINEI1S1?0
According to Strömbeck Pieterse Attorneys (2014), the following documentation

must be completed:
• The Compensation Commissioner’s office should forward the form WCL 55
with a claim number to the employer on receipt and registration of an injury
or disease. This claim number can be checked and followed up on by visiting
http://www.labour.gov.za.
• After each follow-up consultation by the employee, the medical practitioner
must send a WCL 5 form titled ‘Final/progress medical report in respect of
an accident’ to the Compensation Commissioner with the claim number as
received. The WCL 5 form should be submitted at least monthly until the
patient has been stabilised. The documentation is used by the Compensation
Commissioner to determine the number of lost working days of the employee.
• On completion of the treatment and return to work, the medical practitioner
completes the WCL 5 form and forwards the form to the Compensation
Commissioner.
• When the employee returns to work, the medical practitioner must complete
a WCL 6 form titled ‘Resumption report’. This ensures that the employee is
able to finalise the compensation claim.
32

Important tip
The employer and the employee must keep copies of all WCL documents submitted
to the Compensation Commissioner.
2.5 Conclusion
As discussed in this chapter, there has been much development in the health and
safety field over the past few decades and safety legislation is by no means stagnant.
It is imperative that safety professionals keep abreast of changing legislation.
It is equally important that the safety professional is aware of the reporting
procedure for occupational injuries and disease so as to be able to advise employees
and ensure that all the required claim documents are completed and submitted,
copies are received and the employee follows up during and after an incident.
1. Provide a short historical overview on the development of safety legislation on
incident investigation and reporting.
2. Explain South African safety legislation on incident investigation and reporting.
3. Discuss the process of reporting occupational injuries and diseases with
reference to the Occupational Health and Safety Act 85 of 1993 (OHS Act).
4. Discuss the process of reporting occupational injuries and diseases with
reference to the Compensation for Occupational Injuries and Diseases Act 130
of 1993 (COID Act). Refer specifically to the workmen’s compensation claim
(WCL) forms.
33

Chapter 3
Accident causation theories
Learning outcomes
• understand Herbert Heinrich’s domino theory
• understand the difference between Herbert Heinrich’s domino theory and the
updated domino theories of Frank Bird Jr and Edward Adams
• understand James Reason’s ‘Swiss cheese’ model
• understand Russell Ferrell’s human factors theory
• understand Dan Petersen’s incident causation theory
• understand the following theories:
ww systems theory
ww behaviour-based safety theory
ww combination theory
• understand accident causation and management failures
• understand accident causation related to substance abuse.
Key terms
Accident–incident causation theory Job-related factors
Basic cause Lack of control
Behaviour-based safety (BBS) theory Reason model
Combination theory ‘Swiss cheese’ model
Domino theory Systems theory
Human factors theory
3.1 Introduction
Employees are injured every minute in the workplace worldwide, resulting in billions
of rands spent on property damage, health costs and compensation. As discussed in
Chapter 1, Section 1.5 many work hours are lost annually as a result of work-related
incidents, accidents and injuries, leading to huge financial losses. We need to ask the
question: why do these accidents, incidents and injuries happen in today’s modern
society? Various experts have tried to explain this question by developing theories on
the causation of accidents and these theories have evolved over time. In this chapter,
we will look at some common theories of the cause of accidents, such as the:

• domino theory developed by Herbert Heinrich

• human factors theory by Russell Ferrell
• accident–incident theory of Dan Petersen
• systems theory of accident causation by RJ Firenze and others
• behaviour-based safety (BBS) theory of E Scott Geller
• combination theory
• accident causation theory owing to substance abuse.
3.2 Herbert Heinrich’s domino theory

Herbert Heinrich, an American industrial safety pioneer from the 1930s, studied
reports of industrial accidents in an attempt to understand why accidents occur at
work. Based on the approximate 75 000 reports studied, Heinrich determined that
the greater percentage of industrial accidents were caused by unsafe acts created
by the workers themselves (75%) and unsafe conditions leading to minor causes
of industrial accidents (10%). Only a small percentage was related to unavoidable
factors (2%) (Goetsch 2005:37).
Heinrich’s research led to the theory of accident causation, which is better known
as the domino theory (Goetsch n.d.:3). As time passed, the domino theory came to be
considered outdated. Even so, it is said that many of today’s accident theories can be
traced back to Heinrich’s domino theory.
3.2.1 The five dominoes

Heinrich’s domino theory illustrates the sequence of an accident leading to an injury
in a fixed and logical five-step sequence, as shown in Figure 3.1 (Shodhganga n.d.).
The domino sequence can be used to explain the chain of events leading to an injury
as a result of an accident and can be regarded as an ‘event based’ or ‘sequential’
accident causation model. In other words, an accident event takes place in a given
sequence and if one of the five steps does not occur, there will not be an accident
leading to an injury (Goetsch 2005:37).
36

Chapter 3: Accident causation theories
• S
o
en cia Pers
me viro l on • Unsafe act
An nt n- or condition Accident
• Fa
ce ult
str of th • Hazard
y
pers e Hazard
on Injury
Figure 3.1: Heinrich’s domino theory
The essential steps outlined in Heinrich’s domino theory are:
1. Social environment
Heinrich stated in his studies that people learn through socialisation and ancestry.
Through this process, they develop certain personality characteristics, such as
stubbornness, moodiness and recklessness, which could influence individual
behaviour and thereby create unsafe actions.
2. Fault of the person

As with social behaviour, people’s ancestral characteristics may influence them to
behave in a specific manner, thereby creating an unsafe condition that could have
a hazardous or dangerous consequence, such as an injury.
3. Unsafe act or a mechanical/physical hazard

Unsafe acts are committed by people who do not necessarily realise that they are
committing an unsafe act, or who are not really thinking about their actions as
they perform a task. Examples include standing under suspended loads, which is an
unsafe act, and removing safety guards from equipment and machinery, resulting
in a mechanical or physical hazard.
Heinrich’s domino theory says if the unsafe act is prevented, the accident and
injury will not occur.
4. Accident
As stated in Chapter 1, Section 1.3, an accident is an unforeseen, unplanned,
uncontrolled event that results in harm, injury and damage to people, property,
equipment and the environment (Merriam-Webster n.d.).
According to Heinrich’s domino theory, an accident occurs when the social
environment and/or a personal fault results in an unsafe act or condition, such as
when a load in transit falls off, which results in an accident and leads to an injury,
damage and/or property loss.
37

5. Injury
As stated in Chapter 1, Section 1.3.3, an injury is referred to as a state of being
ill, unhealthy and/or not in a good condition (Merriam-Webster n.d.). An injury,
according to Heinrich’s domino theory, is the direct result of an accident caused by
an unsafe act (Goetsch n.d.:33).
3.2.2 Heinrich’s 10 axioms of industrial safety

Heinrich’s research also created the foundation for the ‘axioms of industrial safety’.
According to Goetsch (n.d.:33), Heinrich believed that decision makers need to be
aware of certain aspects about industrial accidents and so he developed the axioms
of industrial safety, which consists of ten statements, namely:
1. Injuries are a result of a series of factors, one being the accident itself.
2. An accident is a result of an unsafe act by a person or employee, or a
physical or mechanical hazard.
3. Most accidents occur as a result of human behaviour.
4. An accident is not always the immediate result of an unsafe act by a person
or an unsafe condition.
5. The reasons behind unsafe acts by employees could provide guidelines for
corrective action.
6. The severity of an accident is mainly unexpected, unplanned and accidental.
However, it could have been prevented.
7. Accident prevention techniques could be incorporated into quality and
production techniques.
8. The best way in which to achieve safety results is if management accepts
responsibility and accountability.
9. The key people in the prevention of accidents are usually supervisors.
10. Accidents have:
• direct costs, such as compensation, liability claims, medical costs and
hospital expenses
• indirect or hidden costs.
Heinrich further emphasised three organisational components as being the cause of
accidents, namely structure, technology and people, whereas in the domino theory
most emphasis is placed on people. However, an analysis of the 10 axioms of
industrial safety reveals that most importance is placed on various ‘people’ factors
in an organisation, unsafe acts by employees, and supervisory and management
roles. Structural factors such as production, quality techniques and physical or
mechanical hazards all play a role in the causation of accidents (Goetsch n.d.:42).
3.2.3 Frank Bird Jr’s updated domino theory

Frank E Bird Jr, at the time director of engineering services for the Insurance
Company of North America, undertook a study of industrial accidents based on
38

Heinrich’s work. According to Leveson et al (n.d.:1), Frank Bird Jr, together with a
colleague, updated Heinrich’s domino theory in 1976. He suggested the following
five key factors that explain the circumstances that lead to injury or loss:
1. Lack of control: Management is considered to be the dangerous domino in
accident causation and is the leading cause of accidents in the workplace
owing to inadequate standards, programmes and follow-up.
2. Basic causes (origins): By recognising the basic causes of accidents,
management is able to develop control systems to manage these basic causes.
Two basic causes are:
• Personal factors: These include a lack of knowledge or skill, poor
motivation, and physical and psychological factors.
• Job-related factors: These include inadequate work and maintenance
standards, inadequate purchasing standards, improper machine and
equipment use, and wear and tear of machinery and equipment.
3. Immediate causes (symptoms): By identifying the immediate causes of
accidents, management is able to implement control measures. Immediate
causes are identified as symptoms of more dangerous underlying problems,
such as poor housekeeping, unauthorised use of machines and equipment,
and a disregard of safety procedures.
4. Accident: An accident is defined as an unforeseen, unplanned, uncontrolled
event that is caused by an unsafe act or unsafe conditions and results
in harm, injury and damage to people, property, equipment and the
environment. Actions that can be taken include reinforcement, modification,
protection or shielding.
5. Injury, damage and/or loss: The result of an injury or damage is loss
that could be either physical harm to people, such as traumatic injury
or adverse mental or neurological effects due to exposure, or damage to
property, including fire. In an attempt to decrease the effect of these losses,
management should implement effective control measures and provide
training to their staff.
Bird’s update of the domino theory highlights the importance of managing the
basic causes of accidents and concentrates on management’s ability to control
injury, damage and loss caused by an accident (Goetsch n.d.:42–43).
Lack of control Basic causes Immediate cause Accident Loss

(management) (origin) (symptom) (contract) (cost)
Figure 3.2: The sequence of events in Bird’s updated domino model
For the definitions of basic causes, immediate causes, an accident, an injury and
damage or loss, see Chapter 1, Section 1.3, and for the definitions of an accident
and an injury, see Section 3.2 in this chapter.
39

3.2.4 Edward Adams’s domino model of accident causation

Heinrich’s domino theory was updated by Edward Adams in 1976. According to
Leveson et al (n.d.:2) and Shodhganga (n.d.:44), Adams renamed the first three
dominoes and sequenced the five key factors as follows:
1. Management structure: This includes organisational objectives and
operations and symbolises the values and beliefs of decision makers, where
strategies and guidelines are developed and priorities determined. It is here
that potential ‘operational errors’ could develop.
2. Operational errors: These are incorrect decisions taken by managers and
supervisors.
3. Tactical errors: Unsafe acts as well as unsafe conditions in the working
environment are caused by employee behaviour.
4. Accident or incident: An accident or incident occurs as a result of an unsafe
act or condition in the management structure, or as a result of operational or
tactical errors.
5. Injury to persons or damage to property: As a result of the accident or incident,
an employee may sustain an injury or property could be damaged or lost.
Management Operational Tactical Accident or Injury, damage

structure errors errors incident and/or loss
Figure 3.3: The domino theory: an accident analysis tool
40

3.2.5 Michael Zabetakis’s updated domino theory

Michael Zabetakis, an American fire safety engineering specialist, believes that an
unsafe act or condition is simply a ‘symptom of failure’ (Shodhganga n.d.:46). In
his opinion, accidents are caused by three basic factors (Shodhganga n.d.:45):
1. poor management policies and decisions
2. personal factors
3. environmental factors.
Management policies and decisions about safety policy, production and safety
goals, record-keeping, inspection and emergency procedures, as well as a lack of
responsibility and accountability, among other things, could result in accidents.
Personal factors such as knowledge, motivation, ability, safety awareness, and
physical and emotional conditions could cause an accident. Environmental factors
that could cause an accident include thermal conditions, dust, gases, vapours,
ventilation, vibration and humidity, among other things (Shodhganga n.d.:46).
Zabetakis also emphasises the importance of energy exchange, claiming that an
accident is caused by the unplanned transfer of an excessive amount of mechanical,
electrical, thermal or ionising radiation energy, or of a hazardous chemical such as
carbon monoxide, carbon dioxide, methane, hydrogen sulphide, sulphur or of any
other hazardous chemical substance.
3.2.6 James Reason’s ‘Swiss cheese’ model

Another version of Heinrich’s domino theory is Reason’s ‘Swiss cheese’ model (see
Figure 3.4). The ‘Swiss cheese’ model adapts terminology and sequencing from
Heinrich’s domino sequence. Reason uses slices of cheese instead of dominoes to
explain the concept of an unsafe act that causes an accident or incident, referred
to by Reason as a ‘mishap’ (Leveson et al n.d.:2, 3). If the holes in the cheese are
aligned, it represents a failure in the system and thus results in a ‘mishap’.
Reason sees human error as the final event but ignores other ‘active failures’.
Active failures can be slips, trips, falls or any form of disruption, destruction or
damage, caused by employees who are in direct contact with systems.
41

Organisational influences
Unsafe supervision
Latent failures
Preconditions for unsafe acts
Unsafe acts
Active failures
Failed or absent
defences
!
hap
Mis
Figure 3.4: Reason’s ‘Swiss cheese’ model

Source: Adapted from Reason, 1990
3.3 Russell Ferrell’s human factors theory

The human factor models of accident causation refer to the fact that employees can
be distracted by internal or external factors. A person can become overloaded as a
result of a disparity between the person’s capacity and what is required from them.
This situation causes the individual to become vulnerable to a potential accident.
Russell Ferrell, Professor of Human Factors at the University of Arizona, promoted
the human factors theory. According to Shodhganga (n.d.:49), Ferrell proposed that
an accident is a result of a chain of events caused by ‘human error’ and consists of
three broad factors, namely:
1. Overload: This refers to the disparity between an employee’s capacity at
a specific time and the weight or burden they have to carry at that time
and under those conditions. The employee’s capacity refers to the person’s
physical condition, natural ability, state of mind, training, expertise, skill,
levels of stress or fatigue. Employees’ state of mind is the result of their
motivational and arousal levels.
Overload can be caused by:
• external environmental factors, for example noise, thermal problems or
distractions
• internal factors, for example emotional stress, illness or personal problems
• situational factors, for example the level of risk and unclear, incorrect or
unlawful instructions.
42

2. Incorrect response (incompatibility): This refers to the fact that an employee

may respond incorrectly as they operate under the conditions of ‘overload’
and so cause accidents, for example:
• when an employee provides an incompatible or inappropriate response
during a specific or stressful situation
• when an employee does not report an obvious and identified hazard
• when the safety guards on machinery have been removed, usually with
the aim of increasing production output
• when safety procedures are ignored.
Incompatibilities include workstation incompatibilities, such as the size, force,
reach and feel, that could result in an incident with injuries (Shodhganga n.d.:50).
3. Inappropriate activities: The employee may act inappropriately because
they did not know how to do the task or deliberately took a risk because
they thought an accident would not happen, or did not understand how
high the cost of an accident would be. According to Goetsch (2005:39–40),
inappropriate activities could be caused by human behaviour, such as when
an employee performs a task without having the required knowledge, skill
and experience and misjudges the degree of risk, which could result in an
accident or injury.
Human factors theory
Overload
Environmental factors Inappropriate responses

• Noise
• Distraction Inappropriate activities
Internal factors
• Personal problems Insufficient knowledge,
Disregarding hazards
• Emotional stress skill and experience
Removing safety guards
Situational factors Misjudging the degree
• Unclear instructions Ignoring safety standards of risk
Figure 3.5: Russell Ferrell’s human factors theory
3.4 Dan Petersen’s accident–incident causation theory

Dan Petersen, a safety consultant, proposed the accident–incident causation theory
in 1982 in a book he wrote titled Human Error Reduction, where he proposed new
aspects but retained many of the human factors theory aspects.
43

Definition
Accident–incident causation theory relates to human error and system failures and
can be viewed as an extension of the human factors theory.
Petersen proposed the following three factors in the accident–incident causation

theory:
1. Overload
Petersen refers to overload as an incompatible capacity load (see Section 3.3 for
an explanation of overload). An individual’s capacity, according to Petersen, is a
person’s talent, physical strength and fitness, knowledge, skill, experience and state
of mind. Petersen refers to a person’s personal and physical state that could include
certain habits such as drug or alcohol abuse, fatigue, pressure, stress, motivational
state, attitude, arousal levels as well as biorhythms (Shodhganga n.d.:50–51).
Load, according to Petersen, arises from performed activities that challenge a
person’s individual capacity. Overloading thus occurs when there is an incompa
tibility and disparity between the person’s capacity and the load.
2. Ergonomic traps
Ergonomics is described as the configuration between a person and their workstation
(Safe Computing Tips n.d.). Faulty workstation design may cause ergonomic traps,
which are described as a design factor that could result in an accident if not
addressed. In the case of ergonomics, the design factor could be the positioning of
the workstation, seating and desk height, which could result in back and neck strain
and eventually cause an occupational disease. Similarly, incompatible displays and
controls may cause so much ergonomic stress that human error occurs.
3. Decision to err (do wrong)

Employees often consciously make the wrong decision. In other words, they make
a decision to err. An example of a wrong decision is where employees purposely
work in an unsafe manner because they believe their method or process used is
more logical and achieves faster results. They may also think that an accident will
not happen to them or that an accident will not have serious repercussions if it
does occur.
System failure also plays a major role in accident causation. According to Goetsch
(2005:43) and Shodhganga (n.d.:51), system failures could be:
• management failure, such as failing to establish a safety policy
• responsibility and authority not clearly defined
• ignoring safety procedures
• incorrect or no orientation training
• insufficient in-house safety training.
44

Accident-incident causation theory
Overload
Ergonomic traps
Decision to err
Pressure
Fatigue Peer pressure
Motivation Incompatible workstation Risk misjudgement
Drugs/alcohol design Management priorities
Stress Incompatible expectations Logical decision
System failure
{ • Human error
• Policy
•
•
Responsibility
Training
{ • Accident
• Inspection
•
•
Correction
Standards { • Injury/damage
Figure 3.6: Accident–incident causation theory
3.5 Systems theory

According to Goetsch (2005:47), systems theory relates to a condition where an
accident could occur from the perspective of a system. A system is the general
framework provided in almost all types of fields, including technology, economy,
biology, psychology, sociology and many more.
Definition
A system is a group of interacting mechanisms that, when working together, creates
an integrated whole (Goetsch 2005:47).
To understand the circumstances under which a system changes to form a new

but possibly unsafe, unwanted condition that could cause an accident, one should
understand and describe the system dynamics in more detail (Shodhganga n.d.:53).
The probability of an accident, according to Goetsch (2005:47), is controlled by
the interaction of components and the variation of patterns that could result in an
incident. By means of systems theory, it is possible to describe the dynamics of the
circumstances under which the components could interact differently and the patterns
could change to cause an incident. These circumstances can transform a given system
into new, and perhaps unwanted, stages or modes of operation (Shodhganga n.d.:53).
45

Systems theory relates to the following factors:

• host or person
• agency or machine
• environment
• information
• decision
• risk
• task or activity performed.
Another systems theory model was developed by RJ Firenze in 1978 and has been
said to be the most widely used model. Firenze considered accident causation
as ‘a system that is a group of interacting and interrelated risk components and
emphasised a harmony between human, machine, and environment for accident
prevention. Instead of considering the environment as being full of risks and
the people as being error prone, he assumed that the chance of an accident is
low under normal, harmonised circumstances. Changes in interrelationships can
increase or reduce the likelihood of an accident’ (Chi & Han 2013:4). Firenze’s
model comprises three blocks that are connected by a feedback loop between the
third and the first block.
Definition
A feedback loop provides information about the success or failure of the system. A
positive feedback loop informs management that the system is functioning correctly and
a negative feedback loop means the system is problematic and needs to be corrected.
According to Shodhganga (n.d.:54), Firenze states that the three connected blocks
of a system are:
1. Person–machine–environment interaction
2. Collection of information
Weighing of risks
Decision making
3. The tasks to be performed to bring about the outcome for block 1 and block 2.
For example, an employee interacts with a machine in the workplace, resulting in
the collection of information. Based on this information and the risks involved in
performing the task or activity, the employee makes a decision about whether to
perform the task or activity. This is illustrated in Figure 3.7.
46

{ {
1 3
Person Collect Make
Weigh risks Task and
Machine Information decisions
activity to
Environment be undertaken
Interaction
Figure 3.7: An example of a systems theory model
Firenze recommends that five factors be considered before starting the activities in
block 2. He recommends that it is particularly important to consider these factors
when stressors such as noise, time constraints, or pressure from a supervisor might
tend to cloud one’s judgement (Shodhganga n.d.:55). The factors are:
1. job requirements
2. employees’ abilities and/or limitations
3. what will be gained if successful
4. what could be lost if failure occurs
5. what would be lost if block 2 is not initiated at all.
3.5.1 Systems theoretic accident model and processes

The systems theoretic accident model and processes (STAMP) is a new accident
causation model that expands accident types and causes using systems thinking.
This system was developed by Nancy G Leveson. In the STAMP model, component
failure accidents are still included, but the causes of accidents are extended to
include component interaction accidents. Safety is reformulated as a control
problem rather than a reliability problem (Song 2012:3). This dynamic model was
developed because poor systems failed to maintain safety performance, and because
of complex changes, safety violations and inadequate safety controls.
According to the STAMP model, unsafe acts and conditions result in accidents
that are caused by human error, organisational and social environmental factors
as well as the lack of management enforcement. Some research has found that
accidents and unacceptable losses are a result of system component failures and the
interaction of both physical and social systems that disrupt safety systems. According
to this research, safety is reconstructed into a system control problem instead of a
component reliability problem. Thus STAMP is based on systems theory to try to find
out as much as possible about the factors involved in a hazard, and to provide clear
guidance as to the control structure leading to the hazard (Song 2012:iii).
According to Leveson et al (n.d.:12) accidents are extremely complex. Each
system should comprise physical controls to ensure safety, but should also include
social, organisational and managerial controls. The aim should be to address
47

the actual process that could result in a lack of control or an accident. When
investigating an accident, it should be determined why the accident occurred by
identifying the physical, social, organisational and managerial controls that are
inadequate or non-existent and that could have caused the accident.
Leveson et al (n.d.:13) found that a basic system and control theory is required
to provide effective control. However, the manager requires an accurate and correct
model of the system being evaluated and controlled. A model of a system is referred
to as a process model, while a human model is referred to as a mental model. These
models are required to establish what control actions are required to keep the
system functioning effectively.
According to Leveson et al (n.d.:12), employers do not aim to harm or injure
employees. However, accidents do happen and in today’s society of economic
instability, employers and employees often take greater risks to increase profits,
and more responsibility is given to single individuals to save costs.
3.6 E Scott Geller’s behaviour-based safety theory

The behaviour-based safety (BBS) theory is one of the most supported accident
causation theories in the safety environment. The BBS theory was developed by
E Scott Geller, who was a psychologist specialising in behavioural theories. Geller
proposed seven factors to ensure safety through behaviour:
1. employee behavioural intervention
2. identification of external factors
3. direct human behaviour with events taking place before desired behaviour
4. positive incentives for desired behaviour as a motivational factor
5. scientific methods expanding on behavioural interventions
6. integration of information
7. planned interventions considering individuals’ feelings and attitudes.
The BBS theory is relevant in most situations where human behaviour is involved
and can be applied in the safety environment as a standard behavioural theory.
According to Goetsch (2005:52), positive reinforcement (incentives and rewards) is
advocated to achieve the desired safety behaviour and to prevent undesired, unsafe
behaviour from becoming established.
The BBS theory is summarised in the ABC model:
A Activators or antecedents of events that precede behaviour: activators are
direct behaviour
B Behaviour of employers, employees and other role players
C Consequences that follow unsafe behaviour: consequence is motivated
behaviour.
According to Goetsch (2005:52), an updated ABC model was developed by Fern
and Alzamora and is called the ABCO model. It includes an additional factor, which
stands for outcome: ‘O’.
48

O Outcomes are long-term results from participating in safe or unsafe

behaviour. The inability to address outcomes signifies a lost opportunity for
motivated employees to participate in safe behaviour.
Goetsch (2005:52) gives the following example: An antecedent of a sign requiring
employees to wear safety goggles could produce the behaviour of putting on the
goggles, the consequence of avoiding an eye injury, and the outcome of being
able to continue working and enjoying time with the family. On the other hand,
the consequence of not wearing goggles could be an eye injury with a potential
outcome of blindness, time off the job, and a reduced quality of life.
3.7 Combination theory

Real situations, such as accidents, are complex and do not always fit neatly into a
theoretical model. Each accident is unique, with its own set of risks. The accident
theories explained in this chapter assist one to find and analyse the reasons for
accidents taking place. A single theoretical model might be adequate to explain
the reasons why most accidents take place. However, a combination theory, which
may combine theories or parts of theories, might be more useful to explain some
accidents. It is suggested that safety professionals combine these theories and use
them to prevent and investigate accidents. However, according to Goetsch (2005:50),
a safety professional should avoid using one specific model continuously.
3.8 Accident causation and management failures

Management is ultimately responsible for the health and safety of employees in the
workplace in accordance with the legal requirements of the Occupational Health
and Safety Act 85 of 1993 (OHS Act). The failure of management to comply with
legal requirements is often the primary cause of workplace accidents.
Responsibilities differ for each level of management. The supervisor, as the ‘first-
level manager’, often has the most direct, hands-on day-to-day responsibilities and
plays an important part in ensuring employee health and safety in the workplace
(Goetsch 2005:55–56).
3.8.1 Management’s responsibilities and failures

As mentioned above, management is responsible for ensuring employee health and
safety and should also set a good example by adhering to health and safety rules.
Managers should reinforce health and safety by:
• including safety in all job descriptions
• providing health and safety training at all levels
• including health and safety in annual performance assessments
• reinforcing and rewarding positive health and safety initiatives.
49

According to Goetsch (2005:56), examples of management failures include:

• poor housekeeping
• improper use of tools, equipment and machinery
• poor health and safety policies and procedures
• not including safety in job advertisements or job descriptions
• ignoring or setting inadequate safety practices and procedures.
3.8.2 Supervisors’ responsibilities

Goetsch (2005:56) suggests that supervisors and safety professionals form a
partnership to supply an effective health and safety programme in the workplace.
A supervisor is assigned health and safety responsibilities in accordance with the
legal requirements of the OHS Act. The safety professional should be available
and act as a safety mentor to the supervisor or any member of the management
team. Goetsch (2005:56) claims that supervisors should be given the following key
responsibilities:
• safety orientation training for new employees
• safety training for all employees
• employee performance monitoring and enforcement of safety policy and
procedures
• assisting the safety professional in conducting accident investigations
• assisting the safety professional in drafting and developing accident reports
• maintaining their knowledge and skills on health and safety
• setting an example for all employees on safety policies and procedures by
demonstrating that safe behaviour is the correct way of undertaking a task.
3.9 Accident causation theory related to substance abuse

Most safety theories emphasise that the use of drugs and alcohol are the root causes
of workplace-related accidents. Substance abuse has a severe effect on the human
system, and could have a devastating effect on the employee and their family.
Many organisations in various industries have implemented compulsory drug
screening and workplace programmes to curb workplace-related injuries linked to
substance abuse. It is essential that safety professionals are vigilant and have the
ability to recognise the signs and symptoms of substance abuse.
3.10 Conclusion
There are many other accident causation theories but the theories discussed in
this chapter are the most common and widely used. These theories can be used
individually or in combination to prevent, investigate and report on accidents.
Many of these theories have been adapted over time to address the needs of our
dynamic society.
50

1. Discuss the domino theory developed by Herbert Heinrich.
2. Discuss the difference between Heinrich’s domino theory and Bird’s updated
domino theory.
3. Discuss Reason’s ‘Swiss cheese’ model.
4. Explain the human factors theory.
5. Explain the incident causation theory.
6. Explain the systems theory, the accident model and process.
7. Explain what is meant by ‘combination theory’ and what the benefits of such a
theory would be.
8. Explain the behaviour-based safety (BBS) theory.
9. Mention the management failures that can cause accidents and provide
examples of each.
10. Discuss accident causation related to substance abuse, specifically drugs and
alcohol.
51

Chapter 4
Accidents and loss
Learning outcomes
• define the following terms:
ww accident
ww consequence
ww hazard
ww incident
ww likelihood
ww risk
ww risk control measure
ww underlying cause
• understand the origins of accident prevention and the safety triangle
• be able to explain incidents and accidents
• discuss the difference between the direct and indirect costs of an incident
• understand the loss causation model
• define ethics in safety and explain leading with safety.
Key terms
Accident Incident
Consequence Likelihood
Domino theory Loss causation model
Ethics in safety Near-miss incident
Hazard Risk
Iceberg model Root cause
Immediate cause Safety triangle
4.1 Introduction
The most common definition of an accident is that it is an unplanned, unwanted
and undesired event caused by substandard actions and conditions that result in
injury, loss or damage. Definitions for accidents vary in different disciplines and
have been adapted and changed over time.

Throughout history, occupational accidents and diseases have had devastating

effects. In South Africa, a number of mining disasters and asbestos-related illnesses
have occurred (see Chapter 1, Section 1.5.2 for information on asbestosis).
4.2 Definitions of an accident

The word ‘accident’ originates from the Latin word accidere, meaning ‘fall upon,
befall, happen, chance’. Various definitions of an accident are given below.
Definitions
According to TheFreeDictionary.com (n.d.), an accident is defined as a sudden,
unexpected event that takes place without expectation, which develops and happens
by chance. It is unforeseen, unexpected, unusual and extraordinary, and does not take
place according to the usual course of events. An accident is a calamity, catastrophe,
disaster and/or unfortunate event, with unexpected injury, loss, suffering and even
death as a result.
The Business Dictionary (n.d.) defines an accident as an unplanned, unexpected event
that occurs suddenly and results in injury, loss, a decrease in resource value and an
increase in liability.
The Health and Safety Executive (HSE n.d.) defines an accident as ‘any unplanned
event resulting in injury, illness, damage or loss to property, machinery or business
opportunity’.
The Health and Safety Executive (HSE 2004:4) further categorises accidents and
incidents as follows:
• Dangerous occurrences: These include reportable, specific events as
stipulated in section 24 of the Occupational Health and Safety Act (OHS Act).
• Undesired circumstances: These are situations that have the potential to
result in an injury or ill health.
• Near-miss incidents: These are events that do not cause harm or injury
but have the potential to result in injury or ill health and could include a
dangerous occurrence.
54

Chapter 4: Accidents and loss
Figure 4.1: An illustration of a near-miss incident
4.3 Aspects of an accident

Accidents take place in a split second and are seen as being of a short duration.
According to Harms-Ringdahl (2013:13), an accident can be related to various
aspects, namely:
• Recovery period or duration of recovery: If a person is suffering from
extensive injuries, the recovery period or duration of the recovery could be
long.
• Consequences: These include unintentional, unexpected and unforeseen
consequences. Most people would avoid being injured at all times. A negative
consequence is when an injury or damage has occurred. Consequences can
range from negligible to devastating.
• Situations: These refer to the area where the accident occurred.
• Extent of the injury or magnitude of the damage: The extent of the injury
and damage could range from minor to major and even catastrophic. There
could have been more than one consequence, ranging from negligible to
devastating, increasing the magnitude of the damage.
55

Accident terminology
Basic cause: See Chapter 1, Section 1.3.6.
Consequence: The unintentional, unexpected and unforeseen result of an
event that is expressed qualitatively or quantitatively. It could
result in one or more outcomes, injuries or losses (Harms-
Ringdahl 2013:13).
Damage: See Chapter 1, Section 1.3.4.
Harm: See Chapter 1, Section 1.3.2.
Hazard: A source of or exposure to danger (OHS Act, s 1) that could
result in injury or ill health, damage to the environment,
damage to property, production loss and increased liability.
Ill health: An adverse health condition, illness or disease, such as
an occupational disease, that can make it impossible
for employees to conduct their daily work activities. It
includes unconsciousness and conditions that may require
resuscitation and hospitalisation (HSE 2004:4).
Immediate cause: The agent or most common cause resulting in an accident,
incident, injury or disease (eg a sharp object or asbestos) (HSE
2004:4). See also Chapter 1, Section 1.3.7.
Incident: An isolated event, arising out of or in connection with a
significant object or objects; an unfortunate, unpleasant
event that could lead to injury, damage and/or loss (Business
Dictionary n.d.). Incidents can be classified as minor or
major events and could have devastating and even multiple
consequences. Also see Chapter 1, Section 1.3.5.
Injury: See ‘major injury’; ‘serious injury’; see also Chapter 1,
Section 1.3.3.
Likelihood: The chance that an unsafe condition or act will take place or
reoccur. Likelihood can be expressed in terms of the following
categories (HSE 2004:4):
certain that it will reoccur in the immediate future
likely that it will reoccur, but not as a daily event
possible that it will reoccur from time to time
unlikely that it will reoccur in the foreseeable future
rare that it will likely occur again.
➠
56

Major injury: Fractures, amputations, loss of limbs or any significant injury

stipulated in section 24 of the OHS Act. See also ‘serious injury’.
Near-miss incident: See Chapter 1, Section 1.3.8.
Risk: The likelihood that an injury or damage could occur. It also
refers to the severity of the consequences should the event
occur. A risk is determined by how many would be affected
and how severe the injuries or damage would be (HSE 2004:5).
Risk control measures: Precautionary steps that are taken in the workplace to control
and manage the risks (HSE 2004:4).
Root cause: The failure to identify risks, for example if a worker falls
from a height, the root cause could be the worker’s lack
of competence, the failure of the safety equipment, or an
organisational failure, such as failing to train the worker
properly (HSE 2004:5). See also Chapter 1, Section 1.3.7.
Safe versus unsafe: See Chapter 1, Section 1.3.1.
Serious injury: An injury that can result in the employee’s inability to
conduct daily work activities, for example the loss of a limb,
that results in the employee being booked off for more than
three consecutive days (HSE 2004:4). See also ‘major injury’.
Underlying cause: A less obvious failure in a system or part of the organisation
that leads to an accident, injury or damage (HSE 2004:4); the
unsafe act or condition (eg the removal of safety guards from
equipment).
4.4 Accident ratio models

As previously discussed, occupation-related injuries and diseases are not a new
phenomenon. Similarly, accident prevention is not a new concept, but the way in
which it is managed in today’s dynamic and ever-changing society is new.
Frank Bird Jr (see Chapter 3, Sections 3.2.1 and 3.2.3), a theorist who studied
the cause of accidents, adapted Heinrich’s accident ratio triangle to develop what is
known as the Bird accident ratio triangle. Bird found that for every 600 near-miss
incidents, at least one would result in a major injury or fatality (see Figure 4.2).
57

1 Major injury/fatality
1 Major/serious injury
10 Minor injuries
29 Minor injuries
Accident and
30 property damage
Property
300 Near-miss
damage 600 incidents
Heinrich’s accident ratio triangle (1931) Bird’s accident ratio triangle (1969)
Figure 4.2: Heinrich’s accident ratio triangle versus Bird’s accident ratio triangle
Over time, this accident ratio triangle was further modified. Two other modifications
are illustrated in Figure 4.3.
10 Minor injuries
Accident and
30 property damage
10 Minor injuries
No visible
600 damage
Property
189 damage
Behaviour
Figure 4.3: Two modified versions of Heinrich’s accident triangle
One of the problems in Bird’s ratio triangle is that there is a grey area between what
is considered to be a major and a minor injury. In addition, many employers and
employees believe that the ratio of 600 near-miss incidents is too high and even
impossible, and that the ratio should be much lower. Therefore, another simplified
ratio triangle was developed by a group of researchers during a study conducted in
the UK. This simplified ratio states that, for every one injury, there are three inci
dents of equipment damage and 30 near-miss incidents, as illustrated in Figure 4.4.
58

1 Injury
Equipment
3 damage
Near-miss
30 incidents
Figure 4.4: Simplified accident ratio triangle
This safety triangle has been further modified into the form of a diamond instead
of a triangle.
1 Injury
2 Equipment
damage
2 Near-miss
incidents
Figure 4.5: Diamond ‘triangle’ of accident causation
The events leading to an accident could be illustrated by three primary outcomes:

1. An injury results in harm to people.
2. Damage to equipment is a direct result of the incident.
3. A near-miss incident is an event that could have resulted in an injury and/or
damage.
Figure 4.6 illustrates the kinds of events that can be defined as accidents, with the
expected accident ratio of 1:3 :60. Loss can occur on a sliding scale ranging from a
catastrophe to a point where nothing occurs. Harm to people or things (including
the environment) and near-miss incidents are the results of accidents or incidents.
59

Loss occurrence Incident type Expected

ratio
Catastrophe
Fatality
Lost time
Harm to people Medical aid 1
First-aid
Occupational illness
Fire and explosion
All possible
incidents Equipment damage
Vehicle damage
Harm to things 3
Abnormal wear and tear
Environmental damage
Production damage
No measurable Near-miss
60
harm incidents
Nothing occurs
Figure 4.6: A practical example of an accident ratio model
4.5 Loss caused by accidents

Accident prevention programmes are often viewed as being too expensive to
implement. According to Goetsch (2005:19) global statics show that accidents are
the primary cause of death and include accident types such as car accidents, fires
and natural disasters. Deaths resulting from these accidents exceed deaths related
to heart disease and cancer. It has been stated that worldwide natural disasters
cause an average of 100 deaths, while workplace-related accidents could cause as
many as 10 000 deaths on average per year.
Considering the actual cost of an accident, the implementation of an accident
prevention programme makes better economic sense than covering the costs of an
accident. The cost of accidents amounts to billions of rands annually and includes
lost wages, lost work hours, medical expenses, property and equipment damage, fire
damage, insurance costs and many indirect, uncalculated costs (Goetsch 2005:19–20).
A number of accident causation theories were discussed in Chapter 3, including
Heinrich’s domino theory and its adaptations.
Two models could be useful in devising an approach to an accident prevention
programme in order to minimise the costs of accidents to the organisation. The iceberg
model, which distinguishes between obvious and hidden causes, and Frank E Bird Jr
and George L Germain’s loss causation model (Figure 4.8), which is based on Heinrich’s
domino theory (see Chapter 3, Sections 3.2.2 and 3.2.3).
60

4.5.1 Iceberg model

The iceberg model is a tool that can be used to differentiate between the obvious
and hidden causes that underlie a particular incident.
The top 10% of the total mass of an iceberg can be seen, while the other 90%
is hidden beneath the waterline. The iceberg model (see Figure 4.7) shows that
accidents can be viewed in the same sense. An accident ‘above the waterline’ is
viewed as an event. These ‘visible’ aspects of the accident include direct costs. An
accident hidden ‘below the waterline’ is viewed as the underlying structure and
root cause of the accident. These ‘invisible’ aspects of the accident involve indirect
and hidden costs.
Event
Direct cost
Underlying structure
Root cause
Indirect cost
Figure 4.7: Iceberg model
The British passenger liner, RMS Titanic, struck an iceberg on 15 April 1912, and
as a result of the accident, more than 1 500 people died (History.com n.d.). This is
a typical example of the unknown and hidden causes of accidents and their costs.
Unknown and hidden costs are costs that are not calculated, such as the cost of
sending a rescue ship, medical expenses, replacement of lost personal items and
funeral costs.
Looking at the example of the accident involving Titanic, the tip of the iceberg,
which was above the waterline, could be considered as a pattern. The underlying
structure or root cause of the accident includes contributing factors such as the
captain who ignored the warning signals that the ship was approaching an iceberg,
as well as travelling at full speed to reach the port before the expected time of
arrival. This accident could have been prevented by reducing the speed and if the
captain could have reacted to the warning signals and changed direction to avoid
colliding with the iceberg. If these measures could have been taken, the captain
could possibly have averted the sinking of the ship.
61

4.5.2 Bird and Germain’s loss causation model

An effective yet simple method to explain and illustrate loss caused by accidents is
to use the loss causation model that was modified in 1985 from Heinrich’s domino
theory by Frank Bird Jr and George L Germain.
The loss causation model can be illustrated as follows:
Immediate causes Incident Loss

Inadequate control Basic causes
Injury
Occupational
Inadequate system disease
Personal Substandard
Standards factors acts Contact with Damage to
Compliance Job factors Substandard energy or property/equipment
conditions substance
Production loss
Financial loss
Environmental
impact
Measurement of Measurement of
Measurement of cause
control consequence
Figure 4.8: Bird and Germain’s loss causation model
The arrows in the diagram represent the ‘principle of multiple causes’. Multiple
causes refer to the cumulative effect of an inadequate system, standards and
compliance, which could contribute to the incident. Problems and incidents are
seldom the result of a single cause.
Examples from the Titanic accident are given to illustrate Bird and Germain’s
sequence of events that lead to injury or loss.
Inadequate control
Inadequate control or a lack of control is thought to be present at the beginning of
all substandard acts or conditions. Controls include the implementation and manage
ment of systems, training and education, written work procedures, job safety analysis,
inspections, investigation and record-keeping (NOSA n.d.). Management functions
are made up of four essential aspects, namely:
1. Planning: Developing an action plan to address incident investigation.
2. Organising: Determining how to arrange and systemise the incident investi
gation action plan.
3. Leading: Leaders of safety teams should ensure that the safety professional
and team members communicate effectively.
4. Controlling: Managing and evaluating the incident investigation action plan
and its implementation; monitoring and reviewing corrective actions.
62

According to Vivian (2006:32), there are three common reasons why management
has inadequate control or a lack of control:
1. Inadequate programmes or systems: The use of a system is referred to as a
programme, which has a beginning and an end, such as an incident or acci
dent investigation. A system is seen as a loop with no beginning or end and
thus involves a continued process of monitoring and improvement, such as the
incident investigation action plan that is continually evolving and being updated.
2. Inadequate programme or system standards: Adequate programme or system
standards are required to manage risks in the workplace. Standards should be
relative to the risks.
3. Inadequate compliance with standards: Programmes and systems are only
acceptable and satisfactory if they comply with set standards. If programmes and
systems do not comply with set standards, they will result in inadequate control.
Example
A lack of control with reference to the Titanic accident includes the iceberg
encountered by the ship’s captain. However, the captain had control over the speed
at which the ship was travelling, and the route.
Basic causes
The basic or root cause of an incident could reveal the substandard practices of
many employers and employees. Basic or root causes of incidents are divided into
two categories:
1. Personal factors: These include physical and physiological factors; mental and
psychological factors; incompetence; lack of knowledge, skills and expertise;
improper motivation; and stress, such as physical, physiological, mental and
psychological stress.
2. Job factors: These include ineffective leadership; defective and inadequate
engineering; ineffective and insufficient procurement of safety equipment;
inadequate maintenance and inadequate maintenance programmes; inadequate
and ineffective tools, equipment, materials and machinery; daily wear and tear
on tools, equipment and machinery; and misuse and abuse of tools, equipment
and machinery.
Example
The captain of the Titanic had 40 years of seafaring experience. The crew and sailors,
however, where untrained and comprised engineers who managed the ship’s engines,
firemen, stewards and gallery staff.
63

Immediate causes
Anything that could go wrong prior to an incident taking place is referred to as
the ‘immediate cause’, which is a visible breach of an accepted practice, code or
standard. The immediate cause of an accident is the direct cause of an accident or
incident, injury or ill health (HSE 2004:4). This could be the result of an employee’s
actions or an existing unsafe condition in the workplace.
As can be seen in Figure 4.8, immediate causes are divided into two categories:
1. Substandard acts: These are also known as unsafe acts. Examples include
unauthorised use of equipment or machinery, use of defective or damaged
equipment, unsafe use or application of equipment, and incorrect positioning
while conducting activities.
2. Substandard conditions: These are also known as unsafe conditions. Examples
include substandard, faulty and malfunctioning tools or equipment, fire or
explosive hazards, extreme temperature variations, and extreme or insufficient
illumination.
The use of any defective, faulty equipment or machinery could result not only in an
injury to the employee but also in further damage to the equipment, machinery or
property, especially in the event of a fire or an explosion (Vivian 2006:30).
Example
The immediate cause of the Titanic accident was the direct impact with the protruding
iceberg against the ship’s hull, which resulted in a rupture.
Incident
An incident does not ‘just happen’. It is the result of contact with an energy source
or substance. The actual occurrence of the accident – a major or minor event –
immediately precedes the loss. This ‘loss-producing event’ (Vivian 2006:27) could
have devastating and even multiple consequences such as harm, injury or damage
to people, property, equipment and the environment.
Loss
Loss refers to the loss, injury or damage that result from the accident. The cost of
accidents could amount to billions of rands with multiple and severe consequences
to the employer, employees and the environment. As shown in the iceberg model,
costs are divided into two groups: those ‘above the waterline’ are direct costs and
those hidden ‘below the waterline’ are indirect costs.
According to Vivian (2006:27), loss includes the following, among other things:
• injuries
• occupational disease
• property or equipment damage
64

• equipment failure
• a loss of company assets due to theft
• production losses
• financial losses
• employee unrest or strikes.
Example
In the case of the Titanic, 1 500 lives were lost. In economic terms, the loss was
astronomical: the ship itself was lost, along with all its equipment and luxurious
fittings and furnishings, and the incredible amount of valuables carried by its
wealthy passengers. Among these were a jewelled copy of the Rubaiyat of Omar
Khayyam, which was valued at £36 162, and a large neoclassical oil painting entitled
La Circassienne au Bain by French artist Merry-Joseph Blondel, which had an
estimated worth of about $2.4 million in 2014 (Wikipedia n.d. RMS Titanic).
The loss causation model should be viewed in terms of a loop for continuous
improvement (see Figure 4.9). However, because management’s main focus is
usually on increasing production and profit, many organisations concentrate only
on treating the symptoms and immediate causes. Instead, they should be looking
for the basic or root cause of the incident or examining the possible inadequate
controls.
Measurement of control
Inadequate control
Inadequate system
Measurement of and standards Measurement
consequence of cause
Basic causes
Loss, injury
or damage Personal and job
factors
Immediate cause
Incident Substandard acts
and conditions
Measurement of cause
Figure 4.9: Loss causation loop
65

4.6 Ethics in safety

Ethics is an integral aspect of everyday life. The meaning of ethics is derived from
the Greek word ethikos, which means ‘morals’ (EHS Today 2007). It is a branch of
philosophy that involves the study of morality and values. In today’s society, ethics
has a far wider meaning as it is associated with corporate social responsibility. Safety
forms part of corporate social responsibility because the employer is responsible
for ensuring the health and safety of employees, customers, shareholders and the
community (EHS Today 2007).
4.6.1 Defining ethics

Employers and employees are responsible and accountable for their actions and
should be aware of the different definitions of ethics and the ‘subfields’ of ethics.
Definitions
Ethics refers to the individual values used to interpret whether the actions and
behaviour of an individual is acceptable and appropriate in a given situation (Stanwick
& Stanwick 2009:2).
Ethics is the study of morality in the cultural environment, and as professional
values, norms and accepted standards of behaviour. Morality implies values that are
supported by society and individuals in that society. Ethical behaviour is individual
behaviour within the limits approved by morality (Goetsch 2005:488).
Goetsch (2005:488) asks the question: ‘How does a safety professional know if an
employee’s behaviour is ethical?’ This type of ethical question is not purely black
and white; it falls within a grey area between what is right and what is wrong and
is often clouded by an individual’s personal experience, self-interest, point of view
and external pressure.
Stanwick & Stanwick (2009:2) ask the following questions relating to actions or
behaviour, and these also apply to safety:
• Are the actions or behaviour consistent with the individual’s responsibilities
and accountabilities?
• Are the underlying rights of the individual acknowledged and respected?
• Is the behaviour regarded as ‘best practice’ in the situation?
• Does the behaviour correspond to the beliefs and values of the individual?
66

Definitions
Business ethics are the shared accepted and appropriate values of an organisation
used to evaluate the behaviour of a specific group of employees (Stanwick & Stanwick
2009:3).
Descriptive ethics is the reporting of facts linked to a specific individual or
organisational ethical behaviour (Stanwick & Stanwick 2009:4).
Analytical ethics or meta-ethics refers to identifying reasons for a specific course of
action that could result in an ethical aspect. Meta-ethics is not only concerned with
the how and when but also asks why (Stanwick & Stanwick 2009:4). Analytical ethics
from a legal point of view could be considered as addressing the motives for a person
or organisation’s behaviour.
Normative ethics is a prescribed course of action attempting to ensure that future
ethical behaviour is followed and maintained and offers an understanding of
what should be done in the future and not what was done in the past (Stanwick
& Stanwick 2009:4).
4.6.2 Ethical and safe leadership

To lead ethically and safely, organisational leaders need to develop a culture based
on dependable values and ethical behaviour. It is important to question whether
management is even interested in business ethics, integrity and, in general, doing
the right thing. Often the general perception outside the business arena is that
management is only concerned with profit (Stanwick & Stanwick 2009:14).
Organisational safety has, over time, provided substantial evidence that doing
the right thing and conducting business in an ethical manner create a positive
environment in all business aspects.
Safety has thus become the backbone of many organisations and the starting point
for dealing with ethical questions and dilemmas. According to EHS Today (2007),
employers are obligated by various ethical principles, namely:
• value of human life: the protection and preservation of human life, which
surpasses all other concerns
• integrity: the commitment to truth and keeping promises, demonstrating and
applying the best of one’s abilities as well as the employer and employees’
commitment and loyalty
• justice: fairness among employers and employees, with the aim of
establishing trust
• the good of many: the realisation of the common good for the individual
and the organisation
• excellence: continual improvement.
67

The commitment to these principles is what drives dedication, passion and integrity
in an organisation. Integrity originates from the Latin word integri, meaning ‘whole
ness’ and is based on employees’ efforts to continually balance personal values with
those of the organisation in an attempt to perform their job activities effectively
(Stanwick & Stanwick 2009:15). If an employee’s integrity is damaged or destroyed,
it could result in negative consequences, such as unethical or illegal behaviour and
personal and professional dysfunction (Stanwick & Stanwick 2009:15).
4.6.3 Guidelines on ethical behaviour for safety professionals

Guidelines could be helpful when attempting to understand and identify what
is ethically right and wrong. Goetsch (2005:488) states that one should first
differentiate between what is legal and what is ethical. An illegal action will
automatically be unethical, but not all legal actions are necessarily ethical in the
circumstances. A person may say ‘I didn’t do anything illegal’, but can they say
‘What I did was not only legal but also ethical’?
Goetsch (2005:489) outlines the following ethical guidelines assuming that the
behaviour being questioned is legal:
• Morning-after test: How will you feel in the morning after taking this
course of action?
• Front-page test: If printed as a story or as front-page news, will you feel
proud or embarrassed?
• Mirror test: How would you feel about yourself if you had to look at
yourself in a mirror after taking this course of action?
• Common-sense test: Listen to your instincts and common sense; if it feels
wrong, it probably is.
Another set of ethical guidelines was developed by Blanchard & Peale (Goetsch
2005:489), based on three simple questions:
• Is it legal?
• Is it balanced?
• How will I feel about myself?
The safety professional has a responsibility to the organisation. If an action is not
legal, it is unethical. Goetsch (2005:489–490) refers to the ‘five P’s of ethical power’
set out by Blanchard & Peale, which are the following:
1. Purpose: You see yourself as an ethical person being guided by your
conscience and feel good about the actions you take.
2. Pride: You have sufficient self-esteem as a person to be guided in making
decisions that are not necessarily popular with others.
3. Patience: You believe that ‘right’ will conquer and you are willing to wait.
68

4. Persistence: You are willing to remain with the ethical decision you have
taken and will persevere until a positive conclusion is reached.
5. Perspective: You will reflect on ethical decisions taken and are guided by
your internal barometer when making ethical decisions.
4.7 Conclusion
Ethics will always be a challenge in business. Deciding what is ethical and carrying
out this ethical course of action is often easier said than done.
Organisational safety could be the stepping stone and starting point to address
aspects of ethical behaviour at all levels of managerial responsibility. The guidelines
outlined in this chapter will guide a safety professional in making the right ethical
choices to prevent accidents and minimise loss to the organisation.
1. Define the following terms:
(a) accident
(b) consequence
(c) hazard
(d) incident
(e) likelihood
(f) risk
(g) risk control measure
(h) underlying cause.
2. Discuss the origins of accident prevention and illustrate the following accident
ratio models:
(a) Heinrich’s accident ratio model
(b) Bird’s accident ratio model.
3. Discuss the concepts of incidents and accidents.
4. Discuss the cost implications of an incident.
5. Discuss the loss causation model developed by Bird and Germain.
6. Discuss ethics in safety.
69

Chapter 5
Incident prevention, investigation and reporting
Learning outcomes
• discuss the legal aspects of incident investigation
• define aspects of incident prevention
• understand what questions should be asked during incident investigation
• discuss the concepts of an incident analysis
• explain the common causes of an incident
• understand why workplace incidents are not reported
• explain the incident investigation process
• understand what is required in an incident investigation toolkit
• discuss the phases of incident analysis
• explain the importance of risk controls, recommendations and action plans
• understand the aspects of incident report writing
• understand the purpose and four ‘Cs’ of report writing
• understand the required content of an incident report
• understand the physical structure of an incident report
• draft, develop and present an incident report.
Key terms
Action plan Organisational factors
Analysis Photography
Biological exposure Physical exposure
Chemical exposure Plant and equipment factors
Clarity Psychological exposure
Completeness Psychosocial exposure
Conciseness Risk control
Correctness Skill-based error
Data collection SMART principles
Human factors System failure
Interviewing Unsafe act
Investigation Unsafe condition
Job factors Witness

5.1 Introduction
Many of us have either been in an accident or have witnessed one. Employees are
killed annually as a result of workplace accidents, with billions of workdays lost
per year. The International Labor Office estimates that 120 million occupational
accidents occur every year worldwide and of these, 210 000 are fatalities (Saari n.d).
Every day approximately 500 employees worldwide do not return home from work
as a result of an occupational injury or death (Saari n.d.).
Some aspects of incidents, including investigating, recording and reporting
incidents, have already been discussed: the Occupational Health and Safety Act 85
of 1993 (OHS Act), with specific reference to sections 24 and 25, is discussed in
relation to reporting occupational diseases and injuries (see Chapter 2, Section 2.2.1).
It is also important to have an understanding of the Compensation for Occupational
Injuries and Diseases Act 130 of 1993 (COID Act), specifically when reporting an
occupational disease as stated in sections 38, 65 and 68 of the Act (see Chapter 2,
Section 2.2.2). The workmen’s compensation claim (WCL) forms that are required
for reporting occupational diseases and injuries are also discussed in Chapter 2 (see
Chapter 2, Sections 2.2.2, 2.2.3 and 2.4).
5.2 Legal requirements of reporting incidents

Section 24 of the OHS Act outlines the requirements of reporting incidents in the
workplace to the inspector. The following incidents in the workplace need to be
reported:
• death of a person
• unconsciousness of a person
• loss of limb or part of a limb
• injuries or becoming ill to the extent that the person could die
• permanent physical defect
• unable to work for a period of at least 14 days
• major incidents
• endangering the health and safety of a person where:
ww a dangerous substance has been spilled
ww an uncontrolled release of a substance under pressure has occurred
ww a fracture or failure of a machine has resulted in flying, falling and
uncontrolled moving objects
• machinery has run out of control.
Regulations 8 and 9 of the General Administrative Regulations of 2003 of the
OHS Act state the administrative procedures that must be followed. These include
the designation of health and safety representatives and the reporting of incidents
and occupational diseases. Regulation 9 of the General Administrative Regulations
also states that a Department of Labour (DoL) form must be used when recording and
72

Chapter 5: Incident prevention, investigation and reporting
reporting incidents titled ‘Annexure 1’ (‘Recording and investigating of incidents’)

(see Chapter 2, Figure 2.1).
The COID Act provides for compensation for an occupational injury, disease or
disablement that was sustained during the course of employment. Compensation
is also provided if an incident, injury or disease causes the death of the employee.
5.3 Incident prevention

Incidents are unplanned and, in most cases, can be avoided. According to Hall (n.d.)
and IntelligentHQ (n.d.), various experts have given guidelines on how to prevent
incidents. These are discussed below.
• Be alert on the job as this will help to prevent incidents and allow for better
productivity.
• Always wear the correct work clothing and personal protective equipment
(PPE).
• The employer has a duty to inform employees about any health and safety
hazards, according to section 13 of the OHS Act. However, the employee also
has a duty to enquire and request details about hazards, unsafe activities and
unsafe conditions.
• Ensure that people are properly trained for the tasks or activities they are
conducting. Never ask people to attempt to perform tasks or activities that
they are not competent to manage.
• Plan and organise work tasks or activities with the aim of identifying
potential hazards before starting work.
• Ensure that you are familiar with the work procedures before beginning a
task or activity. Clarify any unclear instructions.
• Never take shortcuts. Always conduct a task or activity in line with work and
safety procedures.
• Be aware of potential incidents and report them to management immediately.
• Employers should ensure that the correct safety signs are visibly displayed.
• The health and safety of employees should take priority over profit and
productivity.
• Emergency teams must be identified and visible in the workplace and every
employee should listen and actively participate during safety drills.
• When working in hot or cold weather conditions, dress appropriately for the
temperature when a task or activity is conducted.
• Housekeeping is an important aspect to prevent an incident.
• Enter the workplace with a critical eye and note potential safety problems.
73

5.4 Incident investigation

The reason for conducting an incident investigation is to collect information relating
to the cause of the incident, to determine the root cause, and collect supporting
facts and evidence. An incident investigation is not a fault-finding mission and
the aim is not to place blame on an individual. It is conducted to identify ways of
preventing a recurrence of the accident. Goetsch (2005:431) states that the cause of
the accident should be the main focus in an incident investigation.
As discussed in Section 5.2, regulation 9 of the General Administrative Regulations
of the OHS Act requires the completion and submission of the DoL’s ‘Annexure 1’
(‘Recording and investigating of incidents’) form (see Chapter 2, Figure 2.1).
Goetsch (2005:430) refers to two types of incident investigation. These are
incident reports and incident analysis reports. An incident report is completed
for minor incidents and answers the questions of who, what, where and when; it
does not address the why or how. An incident analysis report is completed for
serious incident; answers the questions of who, what, where, when and how, and is
conducted as a formal investigation.
Goetsch (2005:431–432) outlines questions that could be asked during the incident
investigation, irrespective of the nature of the incident, to help find the facts. These
‘5 × W + H’ questions address who, what, when, where, why and how:
• Who
ww What is the injured employee’s job description?
ww What type of work was the employee doing?
ww Is the employee experienced in the task or activity, or new to the job,
task or activity?
ww What was the injured employee doing at the time of the incident?
ww Is the injured employee competent to conduct that specific task or
activity?
ww Was the injured employee authorised to conduct that task or activity?
ww Was the employee supervised during the task or activity?
ww Were there other employees present at the time of the incident
(eyewitnesses)?
ww What were the eyewitnesses doing during the time of the incident?
• What
ww Was the task or activity conducted according to the approved work
procedure?
ww Were the correct equipment and tools being used to carry out the task or
activity?
ww Was/were the job, task, activity, process, equipment, tools or systems
new?
ww What safety rules or procedures are in place and were they being
followed?
ww What was the condition of the site at the time of the incident?
74

• When
ww When did the incident take place?
ww When was the incident reported?
• Where
ww Where did the incident occur?
ww Are there similar recorded incidents at the same site?
ww Were there recommended corrective measures and were they
implemented?
• How
ww How did the incident occur?
• Why
ww Why did the incident occur?
For definitions on the word ‘accident’, refer to Chapter 1, Section 1.3.5 and Chapter 4,
Section 4.2.
5.4.1 Concepts of incident analysis

As discussed under Heinrich’s domino theory (see Chapter 3, Section 3.2), an
incident is the result of a chain of events, owing to the fact that something went
wrong and the result was an unplanned, undesired effect. Jørgensen (n.d.) states
that human intervention could inhibit the chain of events and thus prevent an
injury or damage. Human intervention, on the other hand, could also result in a
more dangerous injury or more extensive damage.
Jørgensen (n.d.) further says that injuries and diseases are linked to one or more
exposure agents over a short (acute) or long (chronic) time period. An acute
exposure agent is an agent that occurs immediately, for example when a person
inhales a chemical that irritates the respiratory tract and it causes the person to
cough and sneeze. A chronic exposure agent is an agent that occurs over an
extended time period, such as exposure to asbestos that results in lung cancer years
later. Jørgensen (n.d.) provides the following examples of exposure agents:
• Physical exposure: This includes noise, radiation, thermal energy (heat and
cold), illumination, and diminished oxygen levels.
• Biological exposure: This includes bacteria, viruses, fungi and biological
agents, for example human or animal blood.
• Physiological exposure: This includes heavy workloads, bad posture and
repetitive movement.
• Psychological exposure: This includes work isolation, stress, violence and
working hours.
• Chemical exposure: This includes acids and alkaline products, solvents, and
cleaning and degreasing agents.
75

Harmful factors are linked to occupational accidents where employees are exposed
to harmful agents. Jørgensen (n.d.) states that harmful factors include:
• energy that involves cutting, planning, pressing and connecting with sharp
objects, saws, edged tools, presses and clamping tools
• conversion of kinetic energy to potential energy and potential energy to
kinetic energy
• electricity, light, radiation and vibration
• toxic chemicals
• corrosives
• excessive stress on the human body
• mental and psychological stressors.
According to Jørgensen (n.d.), exposure sources are dominated by the nature of
the process, technology, product and equipment in a workplace. The control of the
probability of exposure and injury is dependent on three factors (Jørgensen (n.d.):
1. Elimination or substitution safety measures: Total elimination of safety risk
is not possible as risk factors will always be present; there will always be an
amount of inherent risk. Where possible, dangerous exposure sources can be
eliminated or substituted with safer exposure sources.
2. Technical safety measures: This refers to engineering controls that are
implemented to isolate the person from the source of danger by incorporating
barriers.
3. Organisational safety measures: This refers to administrative controls that
are implemented to isolate the person from the source of danger using special
work methods such as reduced exposure times.
Controlling human conduct is not always possible, thus controlling dangers,
hazards and risks becomes a difficult task. According to Jørgensen (n.d.) safety and
risks are dependent on factors that control human behaviour and conduct, namely:
• knowledge of the danger, hazards or risks (it requires the education and
training of the employee as well as identifying and analysing risks)
• opportunity to act in a safe manner
• willingness to act safely and ensure the safety of the workplace.
5.4.2 Common causes of incidents

Heinrich’s domino theory and the revised domino theory of Frank Bird Jr state that
incidents are related to certain key factors (see Chapter 3, Section 3.2). The Health
and Safety Executive (HSE) (2004:7) refers to a chain of failure and errors as bad
luck and being in the wrong place at the wrong time. The HSE (2004:7) classifies
these adverse events according to the following criteria:
76

• The immediate cause is the agent, resulting in injury or disease (eg a sharp
object or asbestos).
• The underlying cause is the unsafe act or condition (eg the removal of safety
guards or noise).
• The root cause is the failure to identify risks (eg competencies, training
requirements and equipment failures).
To control these adverse events, a risk assessment should be undertaken to determine
the cause of an incident. The objective of the risk assessment is to identify adverse
conditions and to implement risk control measures. Goetsch (2005:432–434)
identified the causes of accidents as developed by Dan Hartshorn in the following
categories:
• Personal beliefs and feelings
These include aspects where employees believe that accidents will not take place.
Accidents occur when employees work too quickly, show off, feel they know
everything and even ignore authority. Peer pressure enforces certain employee
behaviour that may result in accidents. The employees may be ignorant or
ignore safety rules and procedures. The good judgement of employees who
are experiencing personal problems could be affected and result in accidents.
• A decision to work unsafely
The employees may feel that the process they are following allows for better
production, regardless of safety procedures. They then make a conscious
decision not to follow safety rules and procedures.
• Discrepancies, mismatch or overload
The employees may have a negative attitude towards the tasks or activities
and may not co-operate with their employer or managers. The tasks may be
too demanding or complex for the employees to follow or may be too boring.
The employees may be focused on personal issues and distracted. They may
also be fatigued, in poor health or suffering from a mental or physical stressor.
Environmental stressors such as noise, heat and dust may also contribute.
• System failures
System failures may result because of the lack of clearly written guidelines
or policies, job procedures and/or poor procurement procedures. Inadequate
or ineffective training, monitoring, supervision and inspection may influence
system failures. The failure to correct identified hazards and risks as well as
inadequate, insufficient or incorrect tools and equipment influence system
failures, as do insufficient or ineffective communication and training.
• Traps
Traps may be the result of poor workstation design, where badly laid out work
areas cause workflow and ergonomic problems. Insufficient and ineffective
ventilation and illumination must be addressed. Defective tools and equipment,
poor processes, uncontrolled hazards and excessive pressure, vibration and
77

force in the workplace result in potential traps that could lead to occupational
injuries or diseases. Excessive stretching, bending and twisting in the workplace
can result in an awkward body posture (ergonomics).
• Unsafe conditions
Unsafe conditions are situations created by employees, colleagues or third
parties that could result in a potential incident, accident and injury. These
unsafe situations may be a result of poor management or the actions of
supervisors. They have the potential to result in an incident, accident and
injury. Unsafe conditions may be created by external elements such as rain,
snow, wind, lightning and darkness.
• Unsafe acts
Unsafe acts could result from ignoring safety rules and procedures, horseplay,
fighting, drugs or alcohol abuse. Unsafe acts could also be caused by the
unauthorised use of tools and equipment, employees failing to ask for guidance
and assistance if uncertain about a task or activity, employees not paying
attention to the task or activity being conducted or improper ergonomics.
5.4.3 Why incidents and diseases are not reported

Occupational incidents, including accidents, injuries and diseases must be reported
to the DoL and Compensation Commissioner as required by legislation. According
to Goetsch (2005:442–443) occupational incidents, including accidents, injuries
and diseases, are not reported because of the following reasons:
• Lack of insight and motivation: A lack of knowledge causes a lack of
insight on the importance of reporting occupational incidents, including
accidents, injuries and diseases. Continued incidents and injuries eventually
lead to poor motivation to submit a report.
• Lack of training: This has an impact on an employee’s knowledge and thus
insight into the importance of early and immediate reporting of occupational
incidents, including accidents, injuries and diseases.
• Lack of responsibility and accountability: A lack of responsibility and
accountability from top management and supervisors may lead to a lack
of motivation as employees may feel they should not report occupational
incidents, including accidents, injuries and diseases, if management does not
do anything to correct the unsafe condition or unsafe behaviour.
• Organisational reputation: This links in with the fear of being disciplined
because employees do not like to be branded as being accident-prone
or blamed for something they could not control as this tarnishes their
reputation.
• Fear of disciplinary action: Employees are afraid of ‘finger pointing’ and
being blamed for occupational incidents, including accidents or injuries, that
are beyond their control. Employers often place the blame for occupational
incidents on employees.
78

• Fear of medical treatment: Many people have an inherent fear of medical

treatment. The thought of having to report to a hospital could place undue
stress on an employee. Thus, some employees avoid medical intervention.
• Dissatisfaction with medical institutions or personnel: There are some
medical specialists or medical interventions that employees would rather
avoid. This could also be linked to the organisation’s first-aid personnel as
the employee may have a dislike or a conflict with that specific person.
• Resistance to stop working: This relates to workaholics who are frequently
opposed to stopping work and would continue to work no matter what the
situation or injury entailed.
• Personal safety record: Employees may not want to tarnish their personal
safety record by reporting an occupational incident, including an accident
or injury, as this may have a negative implication on their performance
assessment.
• Red tape: Red tape, which relates to the adherence to official rules, can be
a major problem as few people like completing paperwork. Reporting an
occupational incident, including an accident, injury or disease, entails a lot
of paperwork. It is essential that simplified reporting methods are developed
for the reporting of minor incidents, with the option of adding to the
documentation should it become necessary.
• Employer and employee attitudes: Attitudes of employers and employees
play an essential role in the reporting of incidents as these are linked to respect
for one another. Employees may feel that the employer will lose respect for
them should they report even the smallest occupational incident, including an
accident, injury or disease. Therefore, these incidents remain unreported.
• Lack of understanding of the importance of reporting: It is found that
employers and employees do not always understand the importance of
reporting incidents, including accidents, injuries and diseases. If the correct
documentation is not submitted, it may not affect them immediately but
it could affect them and their families years later. For example, a disease
related to the exposure to asbestos may only develop decades later and the
documentation of the exposure incident(s) may be required as evidence for
compensation.
5.5 Incident investigation

An accident has previously been defined as an unplanned, undesired event resulting
in harm, injury or property damage (see Chapter 1, Section 1.3 and Chapter 4,
Section 4.2). An employer has a legal obligation to identify the factors that led to
an incident, with the aim of preventing the recurrence of a similar incident.
Incident investigation is both reactive and proactive. The gathering of facts and
data is considered to be reactive, while the investigation and the recommendations
that are made are considered to be proactive (OFSWA n.d.(b)).
79

Definition
An investigation is defined as a formal, structured and systematic process of
collecting information, with the aim of identifying the facts of a specific event. It
is the physical observation of a specific set or series of events (Dictionary.com n.d.).
Incidents are investigated mainly for legal reasons relating to the OHS Act. However,
valuable insight is gained during an investigation as the employer is made aware
of the reason for the incident, and what and why things went wrong. For example,
the employer may gain knowledge on chemical exposures and their related health
implications, and limitations and deficiencies are highlighted in current risk
controls, in order to avoid possible and more serious reoccurrences (HSE 2004:8).
A question that should be asked is who should conduct the incident investigation. In
most organisations, there is a dedicated appointed safety professional who is responsible
for health and safety aspects. It would thus be logical that the safety professional
should conduct the incident investigation. However, some organisations do not have
a dedicated appointed safety professional, and the safety professional cannot be the
only person responsible for the incident investigation. Some organisations may create
an investigation team, while other organisations may appoint an external consultant.
Either way, the health and safety professional should always be involved
and be part of the investigation team. The safety professional conducting the
investigation should furthermore have the authority to make changes in the
organisation, as identified from the incident analysis. All identified root causes
and indicated risk control measures in the management system must be recorded
and the implementation must be monitored (HSE 2004:20). It is also important that
management is supportive of the investigation because without their support the
investigation would be a waste of resources, including time and money.
Goetsch (2005:434) states that there are several approaches that could be followed
in an incident investigation. He suggests that the following be considered when
deciding on a suitable approach:
• organisation’s capacity
• organisation’s structure
• organisation’s management philosophy
• organisation’s health and safety policy and programme
• organisation’s commitment to health and safety
• incident type
• seriousness of the incident
• complexity of the incident with reference to technology and equipment
• trends relating to the reoccurrence of a similar incident.
An incident investigation should take place as soon as possible after the occurrence
of the incident and will depend upon the magnitude and urgency of the incident.
80

The investigation can be categorised into the following five steps (HSE 2004:9–11):
1. Data collection
2. Analysis of information
3. Identification of risk control measures
4. Risk control recommendations and action plans
5. Reports and follow-up.
Step 1: Data collection

Once an incident has been reported, a decision must be made whether to investigate
the event and who should conduct the investigation and collect the data. The HSE
developed a matrix that can be used when making this decision. The HSE matrix
makes use of the worst-case scenario and is illustrated in Figure 5.1.
Consequence
Likelihood
Minor Serious Major Fatal
Probable
Likely
Possible
Doubtful
Rare or uncommon
Risk Minor Low Medium High

Level of investigation Minor Low Medium High
Figure 5.1: Investigation matrix
According to the HSE (2004:13), the levels of the investigation matrix are as follows:
• Minor level: The supervisor will address the aspects that led to the incident.
• Low level: A short formal investigation is required by the supervisor or line
manager to identify the root causes that led to the incident. An effort is made
to prevent a similar incident occurring in the future.
• Medium level: A more detailed investigation is conducted by the supervisor
or line manager and the safety professional, together with the safety
representative, to identify the immediate, underlying and root causes that led
to the incident.
• High level: The team-based investigation is conducted under the supervision
of the director and senior management to identify the immediate, underlying
and root causes.
81

When beginning the data collection process, there are various aspects that the
investigator or the investigation team should address:
• Isolation of the scene
It is essential that the scene where the incident took place is isolated immediately
to avoid contamination of the scene and thus loss of evidence. When there has
been a death or a serious injury, the DoL is required, according to legislation,
to conduct an investigation. Therefore, the scene may not be tampered with
until the investigation has been completed.
Nothing may be removed or moved from the scene, except for the injured
person or corpse. If it is required, the incident scene should be guarded 24/7 to
ensure its integrity and leave it as close as possible to the way it was when the
incident took place (Goetsch 2005:434–435).
• Orientation
The investigators need to orientate themselves regarding the geographical
location as well as the investigation process of the organisation.
• Observation and evidence
The observation of the entire incident scene is crucial to the investigation as
it involves the collection of physical evidence. Observation should include all
stressors, namely:
ww physical (eg noise, dust, illumination and ventilation)
ww chemical (eg chemical vapours and fumes)
ww biological (eg blood, body fluids and body parts)
ww environmental
ww psychosocial
ww ergonomical.
• Photography, videography, sketching and measurements
In today’s society, taking a photograph has become so easy with current
technology, especially smartphones. However, the safety professional should
be aware of the procedures and the organisation’s restrictions on taking
photographs. Prior authority may be required before an incident scene is
photographed. If photographed without authority, it would be appropriate to
inform the organisation’s security and request the required authority to avoid
unnecessary publicity and penalisation.
Photographs and videos should be taken as soon as possible after the incident
to ensure that the correct information is obtained. If there is any doubt that
the scene is relevant, a good rule of thumb is to take the photographs or video.
Rather have them as a record than having nothing to revert to later.
Photographs have limitations because objects are not always shown in
perspective. A photograph of a pothole in the road, for example, could look
small and insignificant. However, if the photograph shows a vehicle that has
driven into a pothole, the size of the pothole will be revealed and the photograph
82

will take on a different significance. When taking photographs or videos it is

advisable to use a known object to depict size perception, as in Figure 5.2. If
an object cannot be used to depict the size, it is suggested that the object is
measured to identify the perspective at a later stage (Goetsch 2005:436).
Figure 5.2: A traffic cone placed in a pothole in the road to depict size and depth
• Interviewing
Interviewing is a useful tool when gathering data on an incident, as valuable
information can be obtained from eyewitnesses. It is essential that the safety
professional is skilled and familiar with interviewing techniques. The ‘5 × W + H’
method can be used to obtain information related to the incident, namely: who,
what, when, where, why and how.
An interview must take place as soon as possible after an incident while
all the information is still fresh in the mind of the witness so as to obtain an
objective account of the incident. Immediate interviewing directly after an
incident also prevents a witness from collaborating with someone to make up
a story, or being threatened or bribed into relaying a different series of events.
According to Goetsch (2005:437), when conducting a witness interview,
whether it is on the scene or in an office, ensure that there are no distractions
and interruptions and that the location does not frighten or intimidate the
witness. A witness must be interviewed individually and in private, away from
others where the account of events could be overheard, thus possibly changing
another person’s perception of events as they viewed it. The witnesses should
be allowed to recall events and answer questions on their own. Do not help or
pressurise the witnesses in relaying events or answering questions.
It is essential that the witness should be at ease during the entire interview
because a witness who feels afraid or intimidated will not relay the correct and
83

full information. The safety professional, who is also the interviewer, must listen
to the witness attentively. The safety professional should not look around and
appear to be bored and must always give their full attention to the witness.
According to Goetsch (2005:438), when interviewing and asking questions,
the safety professional should keep the following in mind:
ww Ask questions in a way that the information received can be listed
chronologically.
ww Ask open-ended questions as far as possible.
ww Do not lead the witness with questions or influence them with gestures,
facial expressions or any non-verbal form of communication.
ww Use a smooth, comforting tone of voice; never use an aggressive or
agitated tone.
ww Do not interrupt unless to clarify what the witness is saying.
ww Remain objective and non-judgemental.
ww When making notes, keep the notes to a minimum and maintain eye
contact as much as possible. It will make the witness feel more at ease and
the witness will be more inclined to provide uninhibited information.
ww Make a mental note of critical information and notarise it after the
witness has withdrawn.
ww Summarise what has been heard and allow the witness to corroborate
this information. Where possible, obtain the witness’s signature on a
final witness report.
ww Some interviewers make an audio recording of the witness statement
to replay it later and ensure that the correct information is given and
that information has not been taken out of context. This allows the
interviewer the opportunity to listen to the witness without having to be
distracted by note-taking.
ww There are, however, some interviewers who are against recording
witnesses as they feel it causes the witness to be less co-operative in
relaying incident events in detail.
ww If recordings are used, the following rules could be effective:
§§ Request permission from the witness to record the interview.
§§ Use a small, inconspicuous recording device. Today many cell
phones have the capability of recording.
§§ Put the witness at ease.
§§ Use an area free of external ambient noise to ensure good sound
quality on the recording.
§§ Ensure that the recording device is in working order and that the
battery power is sufficient.
§§ Discuss any matters unrelated to the incident before beginning the
recording to ensure that only the relevant facts are recorded.
84

§§ Ensure that competent people are available to transcribe the recording.

§§ Review the transcript for the most important information.
• Re-enactment
According to Goetsch (2005:440), the re-enactment of an incident can be
effective and can highlight important information that may have been
overlooked or neglected during the data collection and interview. However,
it is important to remember that a re-enactment could raise the potential for
another incident if not managed correctly. An explanation and simulation of
the incident may be a more effective and safe means of observing any gaps of
knowledge relating to the incident.
Incident investigation toolkit

According to Van Loggerenberg (2012:40), Table 5.1 is an example of the contents
of an incident investigation toolkit that should be kept by the safety professional.
Table 5.1: Contents of an incident investigation toolkit
Item √
1. Clipboard
2. Lined paper or graph paper
3. Coloured pens, pencil, sharpener and eraser
4. Scissors
5. Knife of high quality
6. Incident report template
7. Personal protective equipment (PPE):
• Overalls
• Hard hat
• Safety glasses
• Safety shoes
• Masks required for situations that may arise on site
• Hearing protectors suitable for the noise levels that may be encountered
• Safety gloves
8. Sunscreen and insect repellent
9. Digital camera and/or cellphone
10. Digital recorder and/or dictaphone or cell phone
➠
85

Item √
11. High-powered torch with extra batteries
12. Rotating red light with magnetic base
13. First-aid kit with surgical gloves
14. Barrier tape
15. Oil-based crayons for demarcation
16. Green fluorescent spray paint
17. Measuring tape of 5–10 metres
18. Identification tags
19. Danger tags (eg ‘Do not use’ and ‘Do not switch on’)
20. Three padlocks with keys
21. Sealable plastic bags of different sizes
22. Paper towels
23. Kitbag to place all the items in
Step 2: Analysis of information

The next step after data collection is incident analysis. The objective is to measure
the frequency and seriousness as well as determine risk control measures. If data
collection is not done correctly, a complete data analysis will be of no value.
According to Saari (n.d.), data analysis has two main functions, namely:
1. Determine the cause of the incident and factors that attributed to the cause.
This allows for the safety professional or incident investigator to begin forming
potential safety control measures to prevent another incident.
2. Determine whether similar incidents have occurred in the organisation or
greater industry. The following information will be relevant:
ww workplace identification such as geographical location, work processes
and technology
ww nature of the incident
ww seriousness of the incident related to property damage and employee
injuries
ww causing factors related to the incident such as sources of exposure or
specific working conditions that may have given rise to the incident
ww general working conditions and working situations.
Categories of an analysis
An analysis can be conducted at any level in the organisation and can range
from an individual analysis to a national one. The analysis of general incidents,
86

monitoring and prioritisation is carried out at higher levels, while the analysis of
direct and underlying incidents is conducted at a lower level. Individual analysis
has more specific results than the results of an analysis conducted at a higher level.
According to Saari (n.d.), the analysis is divided into eight categories:
1. Analysis and identification: The aim is to analyse and identify the incident
type and injury type, for example the sector, enterprise, work process,
technology and seriousness of the injury.
2. Monitoring developments: This includes the monitoring of the incident, with
the intention of measuring the effectiveness of the prevention strategy and the
results of the incident analysis.
3. Monitoring trends related to similar incidents: This includes the analysis of
similar incidents to determine how and why they occurred, with the intention
of preventing a similar incident.
4. Measuring the effectiveness of preventative measures already implemented:
Once corrective actions have been applied, they need to be monitored and
measured to determine their effectiveness and ensure that new hazards and
risks have not been created.
5. Monitoring the potential increase of incidents after the implementation of
control measures: Once again, the corrective actions need to be monitored
and measured to ensure that no new hazards and risks have been created that
could cause another incident.
6. Prioritisation: The aim of prioritising is to identify critical areas for
implementing risk controls. This can be achieved by calculating the frequency
and seriousness of incidents.
7. Accident analysis: The aim is to establish both the direct and underlying
causes of an accident. This knowledge is applied when identifying risk control
methods.
8. Analysis for clarification (control analysis): This includes the analysis of
either special areas or areas that have attracted attention, for example special
injury risks. It may include areas where risks have already been identified or
areas of unknown risks.
Phases of an analysis
Regardless of the type of analysis and the level at which it is conducted, an analysis
consists of five phases, as illustrated in Figure 5.3. These include:
1. Identification: The level at which the incident occurred must be identified.
2. Specification: This involves the specific level of occurrence of the incident.
3. Determination: This determines the frequency and seriousness of the incident.
4. Description: This is a description of the source of exposure and risk factors.
5. Examination: Unexpected relationships and developments must be examined.
87

Identification • Level at which the

incident occurred
Specification • Specific level of

occurrence
Determination • Frequency and

seriousness of the
incident
Description • Source of exposure and

risk factors
Examination • Unexpected relationships

and developments
Figure 5.3: Phases of an analysis
Organising and analysing the data

The first step in understanding the reasons for and causes of an incident is to
organise the information collected from the incident investigation. Begin analysing
the data by asking questions related to the immediate cause of the incident. This
includes the place, area, people and processes involved. Identify and record all the
relevant causes and possible risk control measures. The simplest technique to use is
to continually ask ‘why’ until the answers make no sense. The starting point is the
event. For example, Mr Winter broke an arm when he fell off a ladder.
• Injured employee: Mr Winter
• Hazard: A fall to the ground
• Circumstance: Mr Winter fell from a ladder to the ground.
For each of these phrases, ask ‘why’ until the answers are no longer meaningful,
regardless of how many times the question is asked (HSE 2004:20).
88

Mr Winter
Broken arm
Fall to ground
On ladder owing to gravity Falling off ladder Ladder slips
Why? Why? Why? Why?
Ladder not tied

Why?
Ladder broken
Why?
Figure 5.4: Analysis of data
The analysis of the data should indicate an underlying root cause that could have
resulted in the immediate cause of the incident. Record the relevant immediate
causes and potential risk controls identified by the questions asked. The final step
of the analysis of data is environmental considerations.
When human error is identified

What if human errors and violations were identified during the analysis of data as
contributing factors to the incident? The objective of an incident investigation is to
identify the root cause and to prevent a reoccurrence. Human factors would require
careful consideration to ensure that the individual is not blamed and victimised.
By placing blame on an individual, the organisation may lay the foundation for
counter-productivity, alienate employees and discourage a safety culture and thus
a safe working environment. If malicious violation or sabotage is identified, it
could result in counter-productive action by the workforce if disciplinary action is
taken against the perpetrators.
It is essential that careful consideration is given when making a recommendation
in cases where employees are involved as this could also lead to adverse reactions
from employees. The organisational objective is to ensure a just and fair system
where perpetrators are held accountable for their actions without disrupting other
employees (HSE 2004:21).
89

The HSE (2004:21) categorises human error as follows:

• Skill-based error: This is an unplanned lapse in memory that occurs when
conducting a familiar task automatically without thinking. The action can be
performed out of sequence.
Example
A petrol attendant fills up a vehicle with fuel, turns to wash the windscreen, accepts
payment for the fuel and then forgets to remove the fuel nozzle before the owner of
the vehicle drives off. This type of error can be foreseen and prevented with minor
risk controls.
• Rule-based error: There are set rules on how to apply actions in a specific
condition.
Example
When a fire alarm is set off, it is generally understood that employees understand the
rules for vacating the building and premises.
• Knowledge-based error: A knowledge-based error applies when an employee

is confronted with an unfamiliar situation and where the rules are unknown.
Example
A young driver who recently got his driver’s licence notices a warning light on the
dashboard. He thinks it indicates that the car is overheating, but isn’t sure. Is there
a rule indicating what must be done? Does he drive to the nearest petrol station, or
does he stop, switch off the engine, open the bonnet and top up the water level?
• Rule breaking: Rule breaking occurs when there is a deliberate failure or

violation to follow set rules.
Example
An employee removes the safety guard of a circular saw in an attempt to increase
the speed of the equipment and thus the rate of production. The employee sees the
rule as being too restrictive and deliberately breaks the rule at the expense of safety.
During the analysis of data, there are certain factors that must be considered when
human error is identified as the cause of an incident (HSE 2004:23), namely:
• Job factors: If employees are distracted, they will not concentrate on the job
at hand. Other factors include the availability of time and procedures that
may be lacking, ineffective or outdated.
90

• Human factors: These include the physical attributes of the employee such
as the size and strength of the employee, and the knowledge, skill and
experience of the employee in relation to the task at hand. The employee’s
physiological and psychological capabilities are related to fatigue, stress,
morale and potential substance abuse.
• Organisational factors: These relate to work pressure, long working hours
and limited rest periods. Other factors include the quality of supervision,
management’s beliefs and management’s support in the safety culture. The
availability of limited resources also has an influence. Unavailable resources
cause employees to use the wrong objects as tools or equipment, such as
using a chair as a ladder or a knife as a screwdriver. This could potentially
result in injuries.
• Plant and equipment factors: These include clear and understandable
operational instructions for equipment and machinery as well as warning
signal devices on equipment and machinery to detect errors. Other factors
include housekeeping and workplace layout.
Analysis of data to root out risks

The HSE created the ‘Adverse event report and investigation form’ to assist with the
analysis of collected information (see Tables 5.2 to 5.6 depicting adapted parts of this
form) (HSE 2004:66–87). The investigation team can use a similar form to answer
questions on the place, plant, process and people. If the answer to any question is
‘No’, it is an indication that the immediate cause of the incident is being investigated
and attention should rather be placed on the underlying cause of the incident.
Example
Adverse event report and investigation form
Premises and workplace of incident Aspects that should be considered
Building 4, First Street, Johannesburg Industria as underlying causes
Answer the questions if there were any
Risk assessment
Implementation
Communication
contributing factors to the incident.

Co-operation
Competence
Control
Design
Yes
No
Was the workplace used for the

intended purpose? X X X X
Question: Was the workplace used for the intended purpose?

Answer: If the answer is ‘No’, consider the underlying causes such as the design of
the workplace, the implementation of work processes and the risk assessment of the
workplace.
91

Table 5.2 is an example of a form used to identify the immediate causes of an

incident.
Table 5.2: Investigating immediate causes
Immediate causes
Premises and workplace of incident Aspects that should be

___________________________________________ considered as underlying causes
Answer the questions if there were any
contributing factors to the incident.
Risk assessment
Implementation
Communication
Co-operation
Competence
Control
Design
Yes
No
Was the workplace used for the intended
purpose?
Comments:
Plant, equipment and substance

Was the correct equipment available for use?
Comments:
Process and procedures

Was the safe working procedure for the
activity being conducted?
Comments:
People involved
Was the employee performing the task as
trained?
Was the health condition of the employee
good at the time?
Comments:
The identification of the underlying root causes is managed using a similar form,
as shown in Table 5.3.
92

Table 5.3: Investigating underlying root causes
Underlying root causes
Yes
No
Control Comments
Were activities adequately supervised?
Were adequate resources available for conducting
the task?
Were contractors adequately controlled and
supervised?
Co-operation
Were trade union representatives involved in
determining work procedures?
Were arrangements made for the co-operation
with and co-ordination of contractors?
Communication
Were responsibilities and duties clearly set out?
Were responsibilities and duties understood?
Were safe work procedures practical, understood
and communicated?
Competence
Were employees competent for the activity being
performed?
Was the employee in a healthy condition to
manage the task?
Were any training needs identified?
Implementation
Were work procedures effectively implemented?
Were arrangements made for suitable, sufficient
equipment and machinery?
Was there an effective reporting process related to
incidents and injuries?
Risk assessment
Has a risk assessment been conducted?
Were risks correctly identified?
Were recommendations implemented?
Any ‘No’ answer related to an underlying factor needs to be addressed, as it is an

indication of a failing in the health and safety management system.
93

The identified immediate and underlying causes could be listed in a table as a way
to identify potential recommendations and preventative measures, as illustrated in
Table 5.4.
Table 5.4: Identified risks and underlying root causes

Identified risk Risk controls required Underlying root cause(s) Recommendations
Premises or
workplace of
incident
Plant, equipment
and substance
Process and
procedures
People involved
Step 3: Identification of risk control measures

During the analysis of data, the investigation team may have already identified
some risk control measures. These need to be systematically evaluated against
the identified root causes and prioritised for implementation. The HSE (2004:24)
highlights a sequence that can be followed when deciding on the type of risk
controls and their priorities. The organisation would implement risk controls that:
• eliminate risks, for example replace a dangerous lead-based paint with a
safer water-based paint
• prevent the risk at its source, for example place safety guards on machinery
• minimise the risk that is dependent on human behaviour, for example
implement safer work procedures or provide PPE as the last resort.
This step in the incident investigation is a methodical approach. The analysis
of information (Step 2) is assessed and evaluated with the aim of identifying
preventative measures and risk controls. Each risk control must be evaluated based
on its ability to prevent a reoccurrence and how successfully it can be implemented
(HSE 2004:23). However, it must be noted that some of these risk controls could be
more difficult to implement than others.
Step 4: Risk control recommendations and action plans

It is at this stage of the incident investigation that management should become
involved, as management has the authority to make decisions (HSE 2004:24).
Determining where to intervene to address risks requires a sound knowledge of
the organisation and all its processes. Management as well as safety professionals,
employees and safety representatives should develop a risk control action plan that
focuses on risk controls using SMART principles:
94

S = Specific and simple

M = Measurable
A = Achievable and agreed upon
R = Realistic
T = Timescale.
The HSE (2004:24) states that not all identified risk controls can be implemented
at the same time. However, those with the highest priority rating should receive
immediate attention. When determining priorities, the investigation team should be
guided by the likelihood and severity of the risk. When deciding on risk priorities,
the following questions should be asked (HSE 2004:24):
• What is essential to secure the health and safety of the workplace today?
• What can be left for later or another day?
• How high is the risk to employees if the matter at hand is not addressed
immediately?
Risk controls that do not require immediate action are listed in the risk control
action plan, where the responsibility for implementation is assigned to a specific
person, including who does what and when (HSE 2004:23). It is essential that
responsibility is assigned to a person by name and not an organisational position,
as this may be vacant at the time, resulting in no action and implementation.
A realistic time frame must be indicated against each recommendation made to
control a risk and the implementation timetable should be monitored.
The risk control action plan should be reviewed at regular intervals as
determined by management and the investigation team. Any deviations from the
plan should be addressed, reviewed and rescheduled. Progress related to the action
plan should be transparent and made available to all employees in the organisation
(HSE 2004:25).
Step 5: Reports and follow-up

Throughout the incident investigation process, various reports are collected and
completed by team members. One of the most important legal reports used in South
Africa that must be completed is Annexure 1 (‘Recording and investigation of
incidents’) as required by the OHS Act (see Chapter 2, Figure 2.1). There could also
be numerous in-house investigation reports that may have to be reviewed.
Table 5.5 is an example of an incident investigation form that has been adapted
from the HSE ‘Adverse event report and investigation form’ (HSE 2004:29–42). A
similar form can be used by an incident investigation team for a data analysis.
95

Table 5.5: Incident investigation form
Incident investigation form

Premises and workplace of incident
1. Overview
Date and time of incident: Reported by:
Date and time reported: Reference number:
Incident Ill health Minor injury Serious injury Major injury
Short description of incident (what, when, where, who, why and how)
2. Initial assessment

(To be conducted by a health and safety professional)
Type of event
Undesired event Only damage
Near-miss incident Minor
Incident Serious
Ill health Major/fatal
Level of event
High Medium Low Basic
Annexure 1
Completed Not completed
Date completed:
Completed by:
Further investigation required:
Yes No
3. Data collection [See Step 1 on page 81]

When and where did the incident occur?
Name of employee injured:
Names of witnesses:
96

Provide a short description of how the incident occurred.
What activities were being conducted at the time of the incident?
Were there any unusual work activities taking place? Explain.
Are work procedures in place, adequate and updated? Explain.
What injuries or health effects did the employee sustain?
How were these injuries or health effects sustained?
What is the known identified risk?
How did the layout of the workplace influence the incident?
Are maintenance and cleaning programmes in place, sufficient and effective?
Are maintenance registers kept? Yes No

When last was maintenance conducted on the equipment or machine involved in the
incident?
Date:
Were operators trained and competent to operate the equipment or machine?
Yes No
Date of last competency training:
(Complete for each person involved)
Did the nature of material being used influence the incident?

If yes, explain.
97

Were difficulties experienced when using the equipment or machinery.

If yes, explain.
Was safety equipment in place during operations?

If yes, explain.
What other conditions could have influenced the incident?
4. Analysis of information [See Step 2 on page 86]
What immediate, underlying and root causes have been identified?
Was there a similar incident?

If yes, explain.
What risk control measures were recommended for these incidents?
5. Risk control recommendations and action plans [See Step 3 on page 94]
Implementation of risk control measures

Long term
Control measure Target date Responsible person
Medium term
98

Short term
What work procedures need reviewing
Table 5.6 is an example of an action plan for risk control measures that has
been adapted from the HSE ‘Adverse event report and investigation form’
(HSE 2004:40–41). A similar form can be used for a risk control action plan.
99

Table 5.6: Action plan
Action plan
Have the details of the investigation been recorded?

If yes, explain.
What common causes and/or trends have been identified?
Has the cost of the incident been evaluated?

If yes, indicate the estimate or the total cost.
Investigation team members

Name Position Contact number
Findings of report communicated to:

Name Position Contact number Signature or receipt
CEO
Director
Signed by:
Name Position Contact number
_________________________________
(Signature)
5.6 Drafting, developing and presenting an incident report

Safety professionals and safety teams spend a lot of time collecting and analysing
data, and identifying and selecting recommendations. In the final stage of an
investigation, the investigation team is often exhausted and wants to conclude
the incident report. It has been found that incident report writing is often skimped
on and left to the safety professional to complete. This part of the investigation
is probably the most important part as the risks and recommendations must be
communicated to management so that they can be implemented.
Internet accessibility makes finding a template for report writing quite easy.
There are many online templates that can be downloaded and, with minor
adjustments, be customised for a specific organisation.
100

When writing the report, it is important to follow certain guidelines such as the four
‘Cs’: clarity, completeness, conciseness and correctness (Accident Specialist 2007:1).
1. Clarity: The report may be read by a person who does not have in-depth
safety knowledge. It is essential that all safety concepts, terminology and
definitions are clarified for the reader in language that is easily understood.
2. Completeness: Ensure that all aspects leading to the incident have been
identified and addressed. Include all recommendations for preventing and
rectifying risks as a list of priorities from which management can make a
selection.
3. Conciseness: Address and clarify all the important aspects of the report and
do not examine important evidence too frivolously or unrelated evidence too
intensely. A thorough, complete and concise report will ensure that nothing
has been left to chance.
4. Correctness: Calculations and technical aspects in the final report need to
be checked. These include cross-references, diagrams and measurements
as these could either assist or destroy the final outcome of the report and
any rectifications proposed for implementation. Spelling, grammar and the
terminology used should be checked throughout the document to avoid
errors and embarrassment to the team and the organisation.
5.7 Understanding the purpose of an incident report

An incident report is a legal document and can be used in litigation should the
incident turn into a criminal or civil case. In some cases, the report is used in-house
for departmental hearings. These reports are thus said to be forensic in nature. The
safety professional and the safety teams must know the purpose of the report before
even starting the investigation, as this will affect not only the type of investigation
but also the type of report that is drafted. The type of report determines the structure
of the contents, the amount of detail and the layout of the report.
The purpose of a report is determined by two factors (Accident Specialist 2007:3):
1. The type of action required: The type of action required will determine the
length of the report. A report highlighting the failing that led to an incident,
such as a burst tyre, would be shorter and less intense that a report highlighting
criminal negligence owing to insufficient or cheap maintenance, which could
have led to the burst tyre and thus damage, an injury and/or a fatality.
2. The organisation’s reason for requesting the report: The client organisation
requests the report to identify specific risk factors. If the fatality resulted from
a burst tyre of one of the organisation’s fleet vehicles, the organisation could
request a report on the road and weather conditions at the time of the incident.
101

5.8 Understanding the requirements of an incident report

It is assumed that the safety professional understands what the specific technical
content of the incident report should include. It is important, regardless of the
technical language used, that a layperson can easily understand the report.
Therefore, when writing the report, the writer must clarify safety terminology and
ambiguous words and express clearly what is actually meant. All calculations,
measurements and deductions must be clarified and checked.
It is important to take into account the four ‘Cs’ mentioned above (clarity,
completeness, conciseness and correctness) in report writing. The writer should not
assume that the reader will understand what is written. The content of the report
must therefore be clear, complete, concise and correct and the writer should avoid
repetition. However, if evidence is related to more than one factor in the report,
repetition may be necessary. The writer should, however, be wary of repeating
information, evidence and recommendations.
The report should preferably be written in the third person. This provides a
sense of detachment and creates a feeling of independence and objectivity.
5.9 Physical structure of an incident report

The writer of the report should address aspects such as the layout, cover page,
title, spacing, font type and size, stylistic elements such as bolding, italicisation
and underlining, headings and subheadings, headers and footers, page numbers,
spelling and grammar, terminology, technical terms and referencing. Consistency
is of the utmost importance.
The report should create a professional impression and should encourage rather
than deter the reader.
The writer could use a report-writing template from the internet.
5.10 Conclusion
Writing a report may appear simple and easy but it can be a challenging task, even
when using a template. Reports must be written in plain English, using clear and
unambiguous language.
The five steps of incident investigation must be followed in sequence in
order to produce a good report with sound recommendations that could prevent
a reoccurrence of the safety incident. These steps are data collection, the
analysis of information, the identification of risk control measures, risk control
recommendations and action plans, and reports and follow-up.
Bear in mind that the incident report could be used as evidence in litigation.
Only the facts must therefore be included; there is no place for opinions or hearsay.
It would be helpful to have the report proofread by an independent person.
102

1. Discuss the legal requirements of incident investigation.
2. Explain the guidelines for incident prevention.
3. Discuss the questions that are asked during incident investigation.
4. Discuss the concepts of incident analysis.
5. Mention the common causes of incidents.
6. Explain why workplace incidents are often not reported.
7. Explain the five steps in the incident investigation process.
8. What would be required in an incident investigation toolkit list?
9. Discuss the phases of incident analysis.
10. Explain the importance of risk control recommendations and action plans.
11. Discuss the aspects of incident report writing.
12. Discuss the aspects of drafting, developing and presenting an incident report.
13. Explain the four ‘Cs’ of report writing.
14. Discuss the purpose of report writing.
15. Discuss what is required in the content of an incident report.
16. Discuss the physical structure of an incident report.
103

References
Accident Specialist. October 2007. Report. Available: www.accidentspecialist.co.za. (Accessed
23 April 2016).
ACM. Digital Library. Association for Computing Machinery. n.d. Available: http://dl.acm.org.
(Accessed 23 April 2016).
Arbill. n.d. 5 best practices to prevent workplace accidents. Available: http://www.arbill.
com/safety-resources/prevent-workplace-accidents. (Accessed 4 April 2016).
Asbestos.com. n.d. The history of the ban on asbestos. Available: https://www.asbestos.com/
legislation/ban.php. (Accessed 23 April 2016).
Athena Environmental Solutions. 2011. Asbestos: The facts. Available: http://www.athena-
env.co.uk/index.php?p=1_6. (Accessed 25 April 2012).
Business Dictionary. n.d. Accident. Available: http://www.businessdictionary.com/definition/
accident.html. (Accessed 2 June 2016).
Business Dictionary. n.d. Incident. Available: http://www.businessdictionary.com/definition/
incident.html. (Accessed 8 June 2016).
Cancer Knowledge Base. n.d. Asbestos – From miracle mineral to mesothelioma menace.
Available: https://sites.google.com/a/cancerknow.com/cancer-knol/lung-mesothelioma-
asbestos/asbestos---from-miracle-mineral-to-mesothelioma-menace. (Accessed 23 April
2016).
Chamber of Mines of South Africa. n.d. A brief history. Available: http://www.chamber
ofmines.org.za/about/history. (Accessed 24 April 2016).
Chi S & Han S. 2013. Analyses of systems theory for construction accident prevention
with specific reference to OSHA accident reports. International Journal of Project
Management, 31(7), 1027–1041.
De Beer J & Heyns HJ. 2000. Safety Principles and Practices I. Florida: Technikon SA.
Dictionary.com. n.d. Investigation. Available: http://www.dictionary.com/browse/investigation.
(Accessed 23 June 2016).
DMR. Department of Mineral Resources. 2011. About mine health and safety. Available:
http://www.dmr.gov.za/mine-health-a-safety.html. (Accessed 11 May 2016).
DoL. Department of Labour, South African Government. 2003. Guide to general adminstrative
regulations. Available: www.labour.gov.za/.../Useful%20Document%20-%20OHS%20
-%20Gen. (Accessed 17 April 2016).
DoL. Department of Labour, South African Government. 2013. Online submission
portal. Available: https://cfonline.labour.gov.za/OnlineSubmissions/;jsessionid=
41CCB905C65FE77B9DF8CC9B5B206744.CFONLINEI1S1?0. (Accessed 19 May 2016).
DoL. Department of Labour, South African Government. 2015. Annual report of the
Compensation Fund 2014/2015. Available: http://www.labour.gov.za/DOL/down
loads/documents/annual-reports/compensation-for-occupational-injuries-and-
diseases/2015/cfannualreport2015.pdf. (Accessed 17 April 2016).
EHS Today. 2007. The ethics of safety. Available: http://ehstoday.com/safety/best-practices/
ehs_imp_67392. (Accessed 21 June 2016).
Esterhuyzen E & Smit S. 2014. The Basics of Safety Hazards and the Origins of Safety Risk.
Pretoria: Business Press.

Goetsch D. n.d. Theories of accident causation (chapter 3). Available: http://dfwwebpresence.

com/files/FlashDrives/New%20Drive/Classes/occupational%20safety%20and%20
health/To%20Upload/OSH_CH3.pdf. (Accessed 17 April 2016).
Goetsch D. 2005. Occupational Safety and Health for Technologists, Engineers, and Managers.
5th ed. Boston: Pearson.
Hall J. n.d. Top 10 tips on how to prevent an accident at work. Blog post. Available: http://
www.character-training.com/blog/top-10-tips-on-how-to-prevent-an-accident-at-
work. (Accessed 4 April 2016).
Harms-Ringdahl L. 2013. Guide to Safety Analysis for Accident Prevention. IRS Riskhantering
AB. Available: www.irisk.se/sabook/SA-book1.pdf. (Accessed 4 April 2016).
Heinrich HW. 1959. Industrial Accident Prevention: A Scientific Approach. 4th ed. New
York: McGraw-Hill.
History.com. n.d. Titanic. Available: http://www.history.com/topics/titanic. (Accessed 8 June
2016).
HSE. Health and Safety Executive. n.d. Accidents and investigations. Available: http://www.
hse.gov.uk/toolbox/managing/accidents.htm. (Accessed 12 April 2016).
HSE. Health and Safety Executive. 2004. Investigating accidents and incidents. Available:
http://www.hse.gov.uk/pubns/hsg245.pdf. (Accessed 2 June 2016).
IntelligentHQ. n.d. 5 ways to prevent and avoid accidents in the workplace. Available:
http://www.intelligenthq.com/resources/5-ways-to-prevent-and-avoid-accidents-in-
the-workplace. (Accessed 17 April 2016).
IOSM. Institute of Safety Management. n.d. Available: http://www.iosm.co.za. (Accessed 24
April 2016).
IPLOCA. International Pipe Line and Offshore Contractors Association. 2013. Debunking the
‘injury pyramid’: Geneva – 2013. Available: http://www.iploca.com/platform/content/
element/17426/DebunkingtheInjuryPyramidHandout.pdf. (Accessed 8 June 2016).
IRCA. International Register of Certificated Auditors. 2016. Available: http://www.irca.org.
Jacobs B & Jeebhay M. n.d. Occupational health services in South Africa. Available: http://
indicators.hst.org.za/uploads/files/chapter19_99.pdf. (Accessed 14 April 2016).
Jørgensen K. International Occupational Safety and Health Information Centre of the
International Labor Office (ILO-CIS). n.d. Concepts of accident analysis. Encyclopaedia
of Occupational Health and Safety, Part VIII, Chapter 56. Available: http://www.ilocis.
org/documents/chpt56e.htm. (Accessed 4 April 2016).
Klockner K. n.d. Conference Proceedings. Faculty of Sciences, Health and Engineering,
Central Queensland University. Available: http://ositconference.com/wp-content/
uploads/2012/10/OSIT12_Session4B_Klockner.pdf. (Accessed 17 May 2016).
Lang H. n.d. Excavation of the Hawk’s Nest Tunnel, Gauley Bridge, WV, 1930-31, and acute
silicosis. Available: http://pages.geo.wvu.edu/~lang/Geol484/HN-shorter.pdf. (Accessed
23 April 2016).
106

References
Leveson N, Stringfellow M & Thomas J. n.d. A systems approach to accident analysis. Available:
https://www.google.com/url?sa=t&rct =j&q=&esrc=s&source =web&cd =1&ved =0ah
UKEwijj_3hpM7QAhUIIsAKHepXCLcQFggdMAA&url=http%3A%2F%2Fsunnyday.mit.
edu%2Fsafer-world%2Frefinery-edited.doc&usg=AFQjCNFKuewNc7OxaZPiwsJev4A-
V-cmCg&sig2=oGdjBMlzGjdZm-rywy_CAQ. (Accessed 16 April 2016).
Lucas A & Paxton A. n.d. About the Hawk’s Nest Incident – Background for Muriel Rukeyser’s
The Book of the Dead. Available: http://www.english.illinois.edu/maps/poets/m_r/
rukeyser/hawksnest.htm. (Accessed 23 April 2016).
McGiffert M. 2013. The domino theory: An incident analysis tool. Available: http://andrew.
mcgiffert.id.au/blog/the-domino-theory-an-incident-analysis-tool. (Accessed 23 April
2016).
Merriam-Webster. n.d. Safe, unsafe, harm, injury, damage, incident and accident. Available:
http://www.merriam-webster.com/dictionary. (Accessed 17 April 2016).
MESORFA. Mesothelioma Research Foundation of America. n.d. Types of asbestos. Available:
www.mesorfa.org/exposure/asbestos-types.php - 13k. (Accessed 25 April 2012).
Nedlac. National Economic Development and Labour Council. n.d. History of asbestos in
South Africa. Available: http://www.nedlac.org.za/media/6503/app-6.pdf. (Accessed 30
July 2013).
NIOH. National Institute for Occupational Health. n.d. Asbestos. Available: http://www.nioh.
ac.za/?page=asbetos&id=26. (Accessed 5 March 2012).
NOSA. n.d. Available: https://www.nosa.ac.za. (Accessed 17 April 2016).
OFSWA. Ontario Forestry Safe Workplace Association. n.d.(a) The history of the ban of asbestos.
Available: http://www.asbestos.com/legislation/ban.php. (Accessed 23 April 2016).
OFSWA. Ontario Forestry Safe Workplace Association. n.d.(b) Incident investigation:
A self-guided working package. Available: http://www.ofswa.on.ca/downloads/
incident_investigation_self_guided/Incident%20Investigation%20Self%20Guided%20
Working%20Package.pdf. (Accessed 7 November 2011).
O S S Africa. 2008. Summary of the Compensation for Occupational Injury and Diseases
Act, no. 130 of 1993 (with amendments). Available: http://ossafrica.com/esst/index.
php?title=Summary_of_the_Compensation_for_Occupational_Injury_and_Diseases_
Act%2C_no._130_of_1993_(With_Amendments). (Accessed 11 May 2016).
Rielander C. 2012. Safety beginnings. National Safety, 72(3): 34–36.
ROSPA. Royal Society for the Prevention of Accidents. 2014. Activity five: What causes an
accident at work? Available: http://www.rospa.com/road-safety/advice/young-drivers/
young-drivers-at-work/notes/causes. (Accessed 24 April 2016).
Saari J. International Occupational Safety and Health Information Centre of the International
Labor Office (ILO-CIS). n.d. Introduction. Encyclopaedia of Occupational Health and
Safety, Part VIII, Chapter 56. Available: http://www.ilocis.org/documents/chpt56e.htm.
Safe Computing Tips. n.d. Ergonomic causes of disorders. Available: http://www.safe
computingtips.com. (Accessed 17 August 2008).
Safety First Association. 2016. Available: http://www.safety1st.co.za. (Accessed 24 April 2016).
107

Saiosh. South African Institute of Occupational Safety and Health. n.d. Available: http://
www.saiosh.co.za. (Accessed 24 April 2016).
Shodhganga. n.d. Accident theories and organisational factors (chapter 3). Available: http://
shodhganga.inflibnet.ac.in/bitstream/10603/22224/7/07_chapter%203.pdf. (Accessed 17
April 2016).
Signal Safety and Training. 2002. Predictive safety from near miss and hazard reporting.
Available: http://signalsafety.ca/files/Predictive-Safety-Near-Miss-Hazard-Reporting.pdf.
(Accessed 8 June 2016).
Song Y. 2012. Applying System-theoretic Accident Model and Processes (STAMP) to Hazard
Analysis. MEng thesis. McMaster University, China. Available: https://macsphere.
mcmaster.ca/bitstream/11375/11867/1/fulltext.pdf. (Accessed 2 June 2016).
Stanwick P & Stanwick S. 2009. Understanding Business Ethics. New Jersey: Pearson Prentice
Hall.
Stats SA. Statistics South Africa. 2015. SA economy added 7000 formal sector jobs in quarter 3
of 2015. Available: http://www.statssa.gov.za/?p=6009. (Accessed 17 May 2016).
St Paul’s Steiner School. 2013. Accident/incident definition. Available: http://www.stpaulssteiner
school.org/wp-content/uploads/2010/12/accidentvsincident.pdf. (Accessed 2 June 2016).
Strömbeck Pieterse Attorneys. 2014. Injury on duty – What you need to know. Available:
http://www.strombeckpieterse.co.za/article/injury-on-duty-what-you-need-to-know.
(Accessed 19 May 2016).
Study.com. n.d. Four functions of management: Planning, organizing, leading & controlling.
Available: http://study.com/academy/lesson/four-functions-of-management-planning-
organizing-leading-controlling.html. (Accessed 2 June 2016).
Taylor A. 2014. Bhopal: The world’s worst industrial disaster, 30 years later. Available: http://
www.theatlantic.com/photo/2014/12/bhopal-the-worlds-worst-industrial-disaster-30-
years-later/100864. (Accessed 23 April 2016).
TheFreeDictionary.com. n.d. Accident. Available: http://legal-dictionary.thefreedictionary.
com/accident. (Accessed 2 June 2016).
UCC. Union Carbide Corporation. n.d. Bhopal plant history and ownership. Available: http://
www.bhopal.com/Bhopal-Plant-History-and-Ownership. (Accessed 23 April 2016).
Van Loggerenberg N. 2012. Analyse Safety Incidents: UNISA Study Guide for PSMP049.
Pretoria: Unisa Press.
Vivian R. 2006. Risk Management 1: Study Guide 1 (RMN111ZE). Pretoria: Unisa Press.
Wikipedia. n.d. Bhopal disaster. Available: https://en.wikipedia.org/wiki/Bhopal_disaster.
Wikipedia. n.d. Sinking of the RMS Titanic. Available: https://en.wikipedia.org/wiki/
Sinking_of_the_RMS_Titanic. (Accessed 23 April 2016).
108

References
Legislation
Acts
Compensation for Occupational Injuries and Diseases Act 130 of 1993.
Machinery and Occupational Safety Act of 1983.
Mine Health and Safety Act 29 of 1996.
Minerals Act 50 of 1991.
Mines and Works Act 27 of 1956.
Occupational Health and Safety Act 85 of 1993.
Workmen’s Compensation Act 30 of 1941.
Regulations
GN R967. Mine Health and Safety Act, 1996: Regulations. 1997. Government
Gazette 17242 of 14 June 1996.
GN R929. Occupational Health and Safety Act, 1993: General Administrative
Regulations. 2003. Government Gazette 25129 of 25 June 2003.
109


Safetyincident Investigations, 1st Edition

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Safetyincident Investigations, 1st Edition

Uploaded by

Copyright:

Available Formats

SAFETY INCIDENT

Important features which readers will find particularly useful include:

About the author

www.juta.co.za CHERYL RIELANDER

Safety Incident Investigation.indd 17-19 2017/01/03 8:09 AM

Safety Incident Invest (FINAL).indd 1 2017/01/03 8:15 AM

First published 2016

Juta and Company (Pty) Ltd

© 2016 Juta and Company (Pty) Ltd

ISBN 978 1 4851 2486 3 (WebPDF)

Project manager: Marlene Rose

Safety Incident Invest (FINAL).indd 2 2017/01/03 8:15 AM

Safety Incident Invest (FINAL).indd 3 2017/01/03 8:15 AM

Safety Incident Invest (FINAL).indd 4 2017/01/03 8:15 AM

Safety Incident Invest (FINAL).indd 5 2017/01/03 8:15 AM

Safety Incident Invest (FINAL).indd 7 2017/01/03 8:15 AM

Safety Incident Invest (FINAL).indd 9 2017/01/03 8:15 AM

Safety Incident Invest (FINAL).indd 10 2017/01/03 8:15 AM

Safety Incident Invest (FINAL).indd 1 2017/01/03 8:15 AM

1.2 Historical background

Safety Incident Invest (FINAL).indd 2 2017/01/03 8:15 AM

Safety Incident Invest (FINAL).indd 3 2017/01/03 8:15 AM

Revolution with the implementation of safety-related legislation, which is aimed at

Safety Incident Invest (FINAL).indd 4 2017/01/03 8:15 AM

1.3 Concepts and terminology

1.3.1 Safe versus unsafe

Safety Incident Invest (FINAL).indd 5 2017/01/03 8:15 AM

1.3.5 Incident versus accident

1.3.6 Basic cause

Safety Incident Invest (FINAL).indd 6 2017/01/03 8:15 AM

1.3.7 Root or immediate cause

1.3.8 Near-miss incident

1.4 South African workforce

1.5 Incidents and diseases related to improving safety worldwide

Safety Incident Invest (FINAL).indd 7 2017/01/03 8:15 AM

• the Hawks Nest Tunnel disaster

1.5.1 Hawks Nest Tunnel disaster

Safety Incident Invest (FINAL).indd 8 2017/01/03 8:15 AM

Safety Incident Invest (FINAL).indd 9 2017/01/03 8:15 AM

Safety Incident Invest (FINAL).indd 10 2017/01/03 8:15 AM

Dr Irving Selikoff established the International Ban Asbestos Secretariat (IBAS) in

1.5.3 Bhopal gas tragedy

Safety Incident Invest (FINAL).indd 11 2017/01/03 8:15 AM

health standards enforced by the Occupational Safety and Health Administration

1.6 Safety organisations

Safety Incident Invest (FINAL).indd 12 2017/01/03 8:15 AM

According to Goetsch (2005:13), the following are examples of American

1.6.1 South African Chambers of Mines

Safety Incident Invest (FINAL).indd 13 2017/01/03 8:15 AM

Prevention of Accidents Committee. This committee originally concentrated only

1.6.2 National Occupational Safety Association (NOSA)

Safety Incident Invest (FINAL).indd 14 2017/01/03 8:15 AM

1.6.3 International Register of Certificated Auditors (IRCA)

Safety Incident Invest (FINAL).indd 15 2017/01/03 8:15 AM

• planning and leadership

1.6.4 Safety First Association

Safety Incident Invest (FINAL).indd 16 2017/01/03 8:15 AM

1.6.5 Institute of Safety Management (IOSM)

1.6.6 South African Institute of Occupational Safety and Health (Saiosh)

Safety Incident Invest (FINAL).indd 17 2017/01/03 8:15 AM

Safety Incident Invest (FINAL).indd 18 2017/01/03 8:15 AM

Safety Incident Invest (FINAL).indd 19 2017/01/03 8:15 AM

Safety Incident Invest (FINAL).indd 20 2017/01/03 8:15 AM