Unit IA2 : Loss Causation and Incident

Investigation
Theories of Loss Quantitative External and Loss and near-
Part 1

Part 2

Part 3

Part 4
Causation Analysis of Internal miss
Accident and Ill- Reporting and investigations;
Health Data, Recording requirements
Limitations of System and benefits,
Applications and procedures and
Presentation documentation
and involvement
of
communication
with relevant
staff and
representatives.

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 Unit IA2 : Loss Causation and Incident
Investigation

Accident / Incident Ratio Studies

Domino / Multi-Causality Theories

• Single Causal Theories
• Multi Causal Theories

Immediate, Underlying and Root Causes

• Reason’s Model of Accident Causation

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Unit IA2 : Loss Causation and Incident
Investigation
Accident / Incident Ratio Studies
Serious or disabling injury Major or lost time
Minor injuries (first aid)
Minor
Damage accidents
Near-miss accidents No injury accident

Basic Principles:
1. Although actual figures may vary, the basic principle to note is that for every
major incident, there are many more minor or near miss incidents.
2. Minors or near miss incidents has the potential to become a major incident.
3. All events are due to failure to control – even near-misses or minor incidents.
Precautions and action plans are required to prevent reoccurrences.

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 Unit IA2 : Loss Causation and Incident
Investigation

Ancestry and Social

Fault of Person Unsafe Act or Condition Accident Injury
Environment

Heinrich’s Accident Sequence

“A preventable accident is one of five factors in a sequence that results in injury. The injury is invariable caused by an
accident and the accident in turn is always the result of the factor that immediately precedes it.”

Lack of Control by
Basic Causes Immediate Causes Incident Loss
Management

Updated Domino Sequence (Bird and Loftus)

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 Unit IA2 : Loss Causation and Incident
Investigation

Unsafe Act Unsafe Condition

• Human Performance • Any other condition,
that leads to such as physical
accident, such as condition of the
negligence in machinery, poor safe
working with a system of work
machinery

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 Unit IA2 : Loss Causation and Incident
Investigation
Immediate Causes Underlying Causes Root Causes

• Direct Cause of • Less obvious • Ultimate failings

Accident reason which all other
• E.g. Sharp blade • E.g. Removal of failings arrive
of a machine guard of a sharp • E.g. Failure in
cutting a finger blade of a safe system of
machine work to provide
training of
workers, or
failure to assess
risk of the
organization

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 Unit IA2 : Loss Causation and Incident
Investigation

Reason’s Model of Accident Causation

(Swiss Cheese Model)
First Page Credits: http://www.dangreller.com/accidents-errors-and-swiss-cheese/ Next Chapter

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Unit IA2 : Loss Causation and Incident
Investigation

Credits:
RRC NEBOSH International Diploma Study Materials Unit IA2 (Part 1)
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 Unit IA2 : Loss Causation and Incident
Investigation

Loss Event Data can be presented in the form

of:
1. Histogram
2. Pie Charts
3. Line Graphs

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Unit IA2 : Loss Causation and Incident
Investigation
• Requirement of reporting
and recording loss
Reporting incidents are set out in ILO
Requirements Occupational Safety and
Health Convention (C155)
and Procedures and Protocol (P155)
• Sample form Annex A

• Employers should also

record and maintain
Internal reports of minor injuries
Reporting and • Form should be simple to
use and able to record all
Recording important information
• Sample form Annex B

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 Unit IA2 : Loss Causation and Incident
Investigation
Protocol P155 outlines that an employer should:
1. Record and notify occupational accidents, suspected
cases of occupational diseases, dangerous
occurrences and commuting accidents.
2. Inform employees about recording system and
notification
3. Maintain records and use them to prevent
reoccurrence

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 Annex A
Source: UK HSE Form F2508

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Unit IA2 : Loss Causation and Incident
Investigation

Format Use

• Name of affected worker • To help control accidents that

• Date, day and time of accident
• Location of accident • Helps to identify:
• Occupation of the person and job
being done at the time
• Extent of damage / injury
• What happened
• How it happened / control failure
• What caused the accidents
• Immediate remedial action
• Recommendations to prevent
reoccurrence in the future
cause damage and injuries
• Relative importance of various
damage or injuries
• Conditions that caused the
damage or injury
• How often similar type of injury
has happened
• Accident repeaters
• How to prevent reoccurrences in
the future

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 Annex B
Near Miss / Minor Injury Report

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 Annex B
Near Miss / Minor Injury Report
Credits:
BRC Accident / Incident Report Form
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 Annex B
Near Miss / Minor Injury Report
Credits:
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Unit IA2 : Loss Causation and Incident
Investigation
• Identify immediate causes and underlying / root causes of an accident (Understand domino effect)
• Prevent reoccurrence
• Legal Liability
• Data Gathering
Purpose • Identification of Trends

Procedures • 4 Steps Approach

and
Methodologies

• Using Failure Tracing Methods as Investigative Tools

Lessons Learnt

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 Unit IA2 : Loss Causation and Incident
Investigation

4 step accident investigation methodology by

UK HSE Guide Investigating Accidents and Incidents (HSG245)
Analysis of Information

Plan and Implement

Identify Control Measures
Gather of Relevant Information

Via Incident Report Cause and Effect See Unit IA5 Involvement of
Form Identifying Gaps Managers,
Interview Process Supervisors,
Employees’
Representatives and
Others in the
Investigation Process
Managers,
Supervisors
Employees’
Representatives and
Others

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Unit IA2 : Loss Causation and Incident
Investigation

Timing Location

Equipments Who to talk

to?

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 Unit IA2 : Loss Causation and Incident
Investigation
Pointers on Interview Process
• Prompt inspection of the
scene
• Equipments
 Recording Tools; Cameras,
Voice Recorder
 Writing Tools; Pen and Paper
• Interviewing Witness
 Types of Witness
• Primary (victim)
• Secondary (eyewitness)
• Tertiary (people working
around the accident)

 Detectors  Interview Location (Scene of

Incident)
 Portable Lighting
• Question Phrasing
 Who, What, Where, Why,
How

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