Health & Safety Management for Quarries

Topic Three

Accident Aetiology
 Objectives of this Section

• To outline how accidents are caused.

• To demonstrate the role of human error in
accident causation.
• To outline strategies for reducing human
error.
 The Domino Theory
• Accident sequence was likened to a row of dominoes
knocking each other down.

• The accident is avoided by removing one of the

dominoes, normally the middle one or unsafe act.
 Updated Domino Theory
This update introduced two new concepts;
• The influence of management and managerial error.
• Loss, as the result of an accident could be production
losses, property damage as well as injuries.
 Multi-Causation
Behind every accident there lies many contributing factors, causes and sub-causes.

ROOT CAUSE BASIC CAUSE IMMEDIATE INCIDENT/

(Lack of Control) CAUSE LOSS

cause a  cause d  cause f 

cause b cause e
cause c   
 Conclusion

• All accidents whether major or minor are caused,

there is no such thing as an accidental accident!!

• Very few accidents, particularly in large organisations

and complex technologies are associated with a
single cause.

• The causes of accidents are usually complex and

interactive.
 The Role of Human Error in
Accidents
“The actions of people account for 96% of all injuries” –
(DuPont)
“80-90% of accidents are due to human error” (Heinrich
et al, 1980)
“50-90% of accidents according to statistics are due to
human failings” – Kletz (1990)
“We seem to have passed the era where the need was
for further engineering safety guards….What we have
to do is to capture the Human Factor”
In recent years the UK has suffered a large number of
tragic disasters. These include:

• Kings Cross Underground Fire (1987)

31 people killed
• Capsize of the Herald of Free Enterprise
Ferry (1987)
189 people killed
• Clapham Junction rail crash (1988)
35 people killed and 500 injured
• Piper Alpha Oil Rig Explosion (1988)
167 people killed
Two common points arose from the Inquiries:

• The influence of human error in the chain of events

leading to the accident.

• Failures in the management and organisation of safety.

The Traditional Concept of Human
Error

• Look for the immediate cause – an unsafe act.

• Blame the individual concerned.

 The Blame Approach - Options

• You accept that human error is inevitable, shrug your

shoulders, tell him to be a bit more careful and carry
on as before with your fingers crossed.

• Alternatively, you can say as he was responsible, you

should discipline him, perhaps even sack him.

• Give him the benefit of the doubt and retrain the man
(You will almost certainly therefore be reduced to
repeating the training which you know has already
failed!).
 Organisational & Managerial
Failures

Lessons from recent disasters

 Inquiry into the King’s Cross
Underground Station Fire

• Many of the shortcomings in the physical and human state of

affairs at King’s Cross on 18 November 1987 had in fact been
identified before by internal inquiries into escalator fires.....The
many recommendations had not been adequately considered
by senior managers...London Underground’s failure to carry
through the proposals resulting from earlier fires......was a
failure which I believe contributed to the disaster at King’s
Cross.

• I have said unequivocally that we do not see what happened on

the night of 18 November 1987 as being the fault of those in
humble places.
 Inquiry into the Kings Cross
Underground Station Fire

• Although I accept that London Underground believed that safety

was enshrined in the ethos of railway operation, it became clear
that they had a blind spot....
Kings Cross Underground Station
Fire

• I believe this arose because no one person was charged with

overall responsibility for safety. Each director believed he was
responsible for safety in his division, but that it covered
principally the safety of staff. The operations director, who was
responsible for the safe operation of the system, did not believe
he was responsible for the safety of lifts and escalators which
came within the engineering director’s department. Specialist
safety staff were mainly in junior positions and concerned solely
with safety of staff.
 Inquiry into the capsize of the
Herald of Free Enterprise

• Do they need an indicator light to tell them whether the deck

storekeeper is awake and sober? My goodness!!
Inquiry into the Clapham Junction
Rail Crash
• All concerned in management, from the members of the Board
of Directors down to the junior superintendents, were guilty of
fault in that all must be regarded as sharing responsibility for the
failure of management. From the top to the bottom the body
corporate was infected with the disease of sloppiness.

• The direct cause of the Clapham Junction accident was

undoubtedly the wiring errors made by Mr. Hemmingway in his
work in the Junction “A” relay room.
Later, the report goes on to state...

• The concept of absolute safety must be a gospel spread across

the whole workforce and paramount in the minds of
management. The vital importance of this concept .. was
acknowledged time and again in the evidence which the Court
heard ...

But, subsequently it also states..

• The concern for safety was permitted to co-exist with working
practices which ... were positively dangerous ... The best of
intentions regarding safe working practices was permitted to go
hand in hand with the worst of inaction in ensuring that such
practices were put into effect.
Inquiry into the Piper Alpha Oil Rig
Fire

• I am convinced from the evidence ... that the quality of safety

management .... is fundamental to off-shore safety. No amount
of detailed regulations for safety improvements could make up
for deficiencies in the way that safety is managed.
General conclusions which can be drawn from
the above disasters:

• Not one of these organisations had, before the

accidents, any serious reservations about their safety
procedures, organisation or management, yet there
were clearly many problems of which they were not
aware.

• Errors made “at the sharp-end” must be seen in the

wider context of the organisation and management
climate in which they were committed.
• Actions speak louder than words. The best of written
safety policies, the most detailed set of safety rules
and procedures etc. are totally meaningless unless
they are fully resourced, rigorously implemented and
kept under regular review.

• Commitment, positive safety attitudes and motivation

together with constant vigilance throughout the
organisation (but led from the top), are essential to
high safety standards.

• You cannot rely on external prescription to achieve

safety.
 Classification of Human Error
Active/Latent Failures

Active Failures

• Have an immediate consequence.

• Are usually made by front-line people such as
drivers, control room and machine operators.
• Immediately precede, and are the direct cause, of the
accident.
Latent Failures

• Those aspects of the organisation which can

immediately predispose active failures.

• Common examples of latent failures include:

   Poor design of plant and equipment;
   Ineffective training;
   Inadequate supervision;
   Ineffective communications; and
   Uncertainties in roles and responsibilities.
 Latent failures are important to accident
prevention because:

• If they are not resolved, the probability of repeat

accidents remains high regardless of what other
action is taken.

• As one latent failure often influences several potential

errors, removing latent failures can be a very cost-
effective route to accident prevention.
Classifying Active Failures (1)

Human Failures

Violations Human Errors

Routine Mistake Skill-based

s errors

Situational Rule-based Slips of action

Exceptional Knowledge-based Lapses of memory

Slips and Lapses

• Occur in routine tasks with operators who know the process well
and are experienced in their work.

• Action errors which occur whilst the task is being carried out.

• Often involved missing a step out of a sequence or getting steps

in the wrong order and frequently arise from a lapse of attention.

• Typical examples: Operating the wrong control through a lapse

in attention or accidentally selecting the wrong gear.
Classifying Active Failures (2)
Human Failures

Violations Human Errors

Routine Mistake Skill-based

s errors

Situational Rule-based Slips of action

Exceptional Knowledge-based Lapses of memory

Mistakes

• Inadvertent errors that occur when the elements of a

task are being considered by the operator.

• Decisions that are subsequently found to be wrong,

although at the time the operator would have
believed them to be correct.
Violations
• Deliberate deviations from the rules which are deemed
necessary for the safe operation of equipment.

• Breaches in these rules could be accidental or deliberate.

• Violations are seldom wilful acts of sabotage or vandalism.

• The majority stem from a genuine desire to perform work

satisfactorily given the constraints and expectations that exist.
 Latent Failures
King’s Cross Underground Station Fire

The latent failures here included:

• While several minor escalator fires had occurred

previously and had been investigated, apparently no
one in the organisation seriously considered the fact
that a major escalator fire was a possibility -
consequently, as the inquiry states, little effective
action had been taken on the warnings provided by
the minor fires.
King’s Cross Underground Station Fire

• Similarly the inquiry also reported that there were

serious flaws in the managerial and organisational
responsibilities and accountability for safety with
virtually all aspects of the organisation thinking
passenger safety was someone else’s responsibility.
 The Capsize of the Herald of Free
Enterprise
Among the latent failures involved here are the
following:

1. It was impossible for anyone to on the bridge to see whether

the bow doors had been closed prior to setting sail.

2. Although there were organisational procedures in place the

Officer in charge was, effectively, working on the basis of
“faith” rather than any more positive feedback of information.
3. This design latent failure was compounded by the
attitude of the senior management in the memos in
reply to a request for an on-bridge warning device.

4. For a formal request concerning a major safety

issue, from a senior operational manager, to be
treated in such a way clearly indicates that there
was apparently very little credibility given to
potential safety issues.
 Latent Failures
Attitudes to Safety
• A safety culture depends on the attitudes to safety
shown by management and supervisors.

Rules & Procedures

• Studies have shown that safety rules and procedures
are often:
 Written negatively, concentrating on should not be done
rather than on what should be done.
 Impractical.
 In conflict with other rules.
 Training

• Little consideration is given to evaluating the

effectiveness of training.

• Hazard awareness is often assumed rather than

trained.

• Training should concentrate on what is safe, rather

than unsafe, what to do, rather than what not to do.

• Training is not always consistent with the rules and

procedures.
Equipment design & Maintenance

• Limitations in the standard of ergonomics applied to

the design of the equipment/plant increase the risk of
human error.
Strategies for Reducing Human
Error

Reducing human error involves far more than

taking disciplinary action against an
individual.
 Actions for overcoming Active
Failures

Slips and Lapses

• Design improvement is the most effective route for

eliminating the cause of this type of human error.
Slips and Lapses - Typical problems:

 Switches which are too close and can be

inadvertently switched on or off.
 Displays which force the user to bend or stretch to
read them properly.
 Critical displays not in the operators field of view.
 Poorly designed gauges.
 Displays which are cluttered with non-essential
information and are difficult to read.
 Mistakes

• Training is the most effective way for reducing

mistake type human errors.

• Based on defined training needs and objectives.

• Evaluated to see if it has had the desired

improvement in performance.
 Violations

• There is no single best avenue for reducing the

potential for deliberate deviations from procedures.

• Consider the factors that reduce an individuals

motivation to violate which include:

 Under-estimation of the risk.

 Real or perceived pressure from the boss to adopt poor
work practices.
 Pressure from work-mates to adopt their poor working
practices.
 Cutting corners to save time and effort.
 Addressing Latent Failures

The organisation must create an environment

which:

• reduces the benefit to an individual from violating

rules.
• reduces the risk of an operator making slips/lapses
and mistakes.

This can be done by identifying and addressing

latent failures.