Accident Causes during R&M

Activities and Managerial

Measures Effectiveness

Dr George Skroumpelos
Executive VP ACRM S.A. Consulting Group
Adjunct lecturer University of Piraeus

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Scope
 Present the main accident causes in repair
and maintenance (R&M) activities

 Present the Unsafe Mentality Bonding (UMB)

mechanism to interpret the residual risk

 Assess the effectiveness of managerial

measures in R&M-related accident
prevention
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Accident Causes during R&M
Activities and Managerial
Measures Effectiveness

Research Arithmology

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Research Arithmology
 6-year research (1998-2003)
 10 industries  1878 employees  146 in R&M
 Specimen  89 R&M employees interviewed
 105 R&M activities
 Recorded:
 1.122 potential incident scenarios
 8.932 immediate causes
 5.854 basic causes
 2.286 managerial causes

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Accident Causes during R&M
Activities and Managerial
Measures Effectiveness

The cause-effect chain mechanism

&
The Unsafe Mentality Bonding (UMB)

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The chain cause-event
mechanism
The risk assessment process (preventive)

The investigative process (corrective)

Managerial Basic Immediate Incident

Causes (MC) Causes (BC) Causes (IC)
Management Supervisory Worker
related related related

Sequence of events
The chain cause-event mechanism

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Research Methodology
 The Incident Recall Method
The researcher recorded the incidents
(accidents and near accidents) experienced
by personnel and not only the ones recorded
or reported which are filtered by the assessor
thus limiting the latter’s subjectivity

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UMB: Unsafe Mentality Bonding
CULTURE Bonding improbable

MC=Managerial Causes
BC=Basic Causes
IC=Immediate Causes
Inc=Incidents
UMB=Unsafe Mentality Bonding MC MC MC

UMB

MANAGERIAL Level Measures lead to

STRONG RESISTANCE to UMB
Unsafe
behaviour
The UMB
BC BC BC BC
The investigation mechanism
UMB
process
SUPERVISORY Level Measures
WEAKER RESISTANCE to UMB
Unsafe
behaviour
UMB=
lead to
The cause-event The behaviour of a
chain worker who may ignore
mechanism the safety measures
because of his total
IC IC IC IC IC
perception of
UMB management’s general
TECHNICAL /FIRST LINE Level Measures
TRIVIAL RESISTANCE to UMB
attitude or of the working
Unsafe environment safety and
behaviour
lead to not because he is not
aware of the danger
Inc Inc Inc Inc Inc Inc

The cause-event chain mechanism and the effect of Unsafe Mentality Bonding (UMB) depicted by the horizontal dotted lines

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 Table 2: Immediate, Basic and Managerial Cause list
A. Immediate Causes

UA.Unsafe Acts UC. Unsafe Conditions

UA1.Acting without authorization UC1.Guards out of place

UA2.Acting without personnel warning UC2.Insufficient guarding
UA3.Guard bypassing UC3.Insufficient working space
UA4.LOTO violation UC4.Insufficient access
UA5.Improper material handling UC5.Heat/ ignition sources
UA6.Non-use of equipment UC6.Unexpected movement
UA7.Use of defective equipment UC7.Protruding parts
UA8.Misuse of equipment UC8.Unstable material storage
UA9.Non-use of PPE UC9.Insufficient equipment
UA10.Use of defective PPE UC10.Defective equipment
UA11.Misuse of PPE UC11.Insufficient work area demarcation
UA12.Improper manual handling UC12.Insufficient equipment/ installation demarcation
UA13.Maintenance of machinery/ equipment in motion
UC13.Insufficient material labeling
UA14.Maintenace of electrical machinery/ equipment under voltage UC14.Insufficient Lockout - Tagout
UC15.Improper working outfit/ jewelry
UA15.Rules violation UC16.Improper-insufficient PPE
UA16.Bantering UC17.Insufficient lighting
UA17.Working under influence UC18.Insufficient air conditioning
UA18.Repetitive motion UC19.Vibration
UA19.Improper working posture UC20.Insufficient housekeeping
UA20.Overexertion

B. Basic Causes

WM. Wrong Motive PF. Personal Factots OF. Occupational Factors

WM1.Saving time (hastiness) PF1.Lack of knowledge-skills OF1.Insufficient job specifications

WM2.Saving effort PF2.Lack of attention - OF2.Insufficient design
WM3.Seeking focus OF3.Insufficient maintenance
ease, comfort PF3.Familiarisation with danger OF4.Normal wear
WM4.Attract attention OF5.Abnormal wear
WM5.Display independence OF6.Insufficient equipment
WM6.Seeking approval
WM7.Express hostility

WM8.Seek financial rewards

C. Managerial Causes

M1.Insufficient programming
M2.Lack of programming
M3.Insufficient specifications - programming - procedures
M4.Lack of specifications-programming-procedures
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M6.Lack of training ent
M7.Insufficient enforcement
M8.Lack of enforcement
Table 4: Incident Managerial Causes and corresponding recommended measures

Managerial Causes Classification Corresponding Measures

M1. Partial or total lack of a Health & Safety 1S. Written policies, procedures, guidelines, rules,
System safe methods of work and action planning for
continual improvement

M2. Partial or total lack of internal 2C. Training, meetings, verbal & non-verbal
Communications internal communication techniques

M3. Partial or total lack of managerial Enforcement 3E. Continuous safety supervision, auditing, &
followup on the implementation of the above

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Measures implementation
 Effective measures implementation

 Interruption of the causal factor – potential incident scenario

chain mechanism corresponding to the recommended measures

 Probable Incident Scenario  Improbable Incident Scenario

 Trivial probability of incident scenario  no accident (?)

(Trivial = non-zero due to UMB)

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Accident Causes during R&M
Activities and Managerial
Measures Effectiveness

RESULTS

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Appearance subcategory frequency
A. Immediate Causes
UA.Unsafe Acts
UA1.Acting without authorization
UA2.Acting without personnel warning
UA3.Guard bypassing
UA4.LOTO violation
UA5.Improper material handling
UA6.Non-use of equipment
UA7.Use of defective equipment
UA8.Misuse of equipment
UA9.Non-use of PPE
UA10.Use of defective PPE
UA11.Misuse of PPE
UA12.Improper manual handling
UA13.Maintenance of machinery/ equipment in motion
UA14.Maintenace of electrical machinery/ equipment under voltage
UA15.Rules violation
UA16.Bantering
UA17.Working under influence
UA18.Repetitive motion
UA19.Improper working posture
UA20.Overexertion
B. Basic Causes 100%
WM. Wrong Motive 29% PF. Personal Factots 37%
WM1.Saving time (hastiness)
WM2.Saving effort
WM3.Seeking ease, comfort
WM4.Attract attention
WM5.Display independence
WM6.Seeking approval
WM7.Express hostility
WM8.Seek financial rewards
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100%
59% UC. Unsafe Conditions 41%
UC1.Guards out of place
UC2.Insufficient guarding
UC3.Insufficient working space
UC4.Insufficient access
UC5.Heat/ ignition sources
UC6.Unexpected movement
UC7.Protruding parts
UC8.Unstable material storage
UC9.Insufficient equipment
UC10.Defective equipment
UC11.Insufficient work area demarcation
UC12.Insufficient equipment/ installation demarcation
UC13.Insufficient material labeling
UC14.Insufficient Lockout - Tagout
UC15.Improper working outfit/ jewelry
UC16.Improper-insufficient PPE
UC17.Insufficient lighting
UC18.Insufficient air conditioning
UC19.Vibration
UC20.Insufficient housekeeping
OF. Occupational Factors 34%
PF1.Lack of knowledge-skills OF1.Insufficient job specifications
PF2.Lack of attention - focus OF2.Insufficient design
PF3.Familiarisation with danger OF3.Insufficient maintenance
OF4.Normal wear
OF5.Abnormal wear
OF6.Insufficient equipment
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 Appearance frequency in each cause subcategory
A. Immediate Causes
UA.Unsafe Acts 100 % UC. Unsafe Conditions 100 %
UA1.Acting without authorization 11% UC1.Guards out of place
UC2.Insufficient guarding
UA2.Acting without personnel warning UC3.Insufficient working space

UA3.Guard bypassing UC4.Insufficient access

UA4.LOTO violation
UA5.Improper material handling
UA6.Non-use of equipment
UA7.Use of defective equipment
UC5.Heat/ ignition sources 13%
UC6.Unexpected movement
10% UC7.Protruding parts
UC8.Unstable material storage 12%

UA8.Misuse of equipment UC9.Insufficient equipment

UA9.Non-use of PPE UC10.Defective equipment
UA10.Use of defective PPE
UA11.Misuse of PPE UC11.Insufficient work area demarcation
UA12.Improper manual handling
UA13.Maintenance of machinery/ 15% UC12.Insufficient equipment/ installation
equipment in motion 12% demarcation
UA14.Maintenace of electrical machinery/ UC13.Insufficient material labeling
equipment under voltage
UA15.Rules violation UC14.Insufficient Lockout - Tagout 13%
UA16.Bantering
UA17.Working
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UC15.Improper
Asset Managem
working outfit/ jewelry 14
UA18.Repetitive motion ent UC16.Improper-insufficient PPE
UA19.Improper working posture
 Appearance frequency in each cause subcategory

B. Basic Causes
WM. Wrong 100 % PF. Personal OF. Occupational Factors
Motive Factots 100 % 100 %
WM1.Saving time PF1.Lack of OF1.Insufficient job
(hastiness)
37% knowledge-skills specifications
43%

WM2.Saving effort26% OF2.Insufficient design

38%
PF2.Lack of attention
WM3.Seeking ease, - focus OF3.Insufficient maintenance
comfort
43% OF4.Normal wear
WM4.Attract attention PF3.Familiarisation
with danger OF5.Abnormal wear

WM5.Display OF6.Insufficient equipment

independence

WM6.Seeking approval

WM7.Express hostility

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WM8.Seek financial ent
rewards
 Appearance frequency in the incident scenarios in
R&M activities (% of incidents caused)

C. Managerial Causes
M1. H&S System M2. Communications M3. Enforcement

10,3% 2,2% 14,4%

M1+M2. M1+M2. M1+M3.
H&S System + Communications + H&S System +
Communications Enforcement Enforcement

15,2% 3,4% 23,8%

M1+M2+M3. H&S System + Communications + Enforcement

30,7%
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 Managerial measures effectiveness in R&M
activities (% of incidents prevented)

C. Managerial Measures
S1. H&S System C2. Communications E3. Enforcement

10,3% 2,2% 14,4%

S1+C2. C2+E3. S1+E3.
H&S System + Communications + H&S System +
Communications Enforcement Enforcement

27,7% 20,0% 48,5%

S1+C2+E3. H&S System + Communications + Enforcement

100%
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Accident Causes during R&M
Activities and Managerial
Measures Effectiveness

INTERPRETATION OF
RESULTS

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Causal factors in R&M activities
 “Untidy” work  Disassembling, laying out tools,
occupying floor space  Poor housekeeping
 Specialized knowhow  Activities non-self
explanatory  Lack of focus
 Repetitive tasks  Trained highly skilled
professionals  Overconfident behaviours
 “Non-production” work  Time pressure to reduce
rundown times  Unsafe behaviours
 Task diversity and complexity  Insufficient
written procedures  Insufficient work method
statements (e.g. Lockout-tagout)
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Managerial measures
effectiveness in R&M activities
 Highly skilled and trained personnel 
Enforcement is individually the most effective
measure
 Highly skilled and trained personnel + complex
tasks  H&S procedures + Enforcement is the
most effective combination

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Accident Causes during R&M
Activities and Managerial
Measures Effectiveness

CONCLUSIONS

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Conclusions on human factors in
R&M activities
 The probability of an incident can never be zero,
the residual risk varying from 2-5% mainly
because of the involvement of the unsafe
mentality bonding (UMB).
 The contribution to accidents of the unsafe acts
with respect to unsafe conditions presented in
similar studies appears overrated (80%) in
relation to the results of this study (60%).

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Conclusions on the incident
causes in R&M activities
 Housekeeping is a top priority issue that all
business operations must address. The
implementation of a 5S system would definitely
facilitate this effort especially in R&M activities.
 The development of R&M safe work methods is
imperative. A job safety analysis must be
conducted in some cases.

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Conclusions on managerial measures
effectiveness in R&M activities
 The enforcement of developed R&M detailed
procedures in which safety is an integral part is the
most effective managerial measure (50% incident
probability reduction).
 Close supervision and enforcement should focus
on hastiness and minimum effort safety violations.
 Training acts only as a catalyst; it is only
effective in combination with other managerial
measures.

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Accident Causes during R&M Activities
and Managerial Measures Effectiveness
More Information: www.acrm.gr / gs-rms@otenet.gr

Only easy questions please !!!

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