ACCIDENT AND INCIDENT INVESTIGATION

INCIDENT CAUSATION ANALYSIS METHODOLOGY (ICAM)

FACTORS INFLUENCING OCCURENCE OF INCIDENTS
THE CAUSATION PATHWAY
Written by Nigel Pitt IMORSA.com
Incident Accident Investigation - Causation Pathway June 13, 2013

TABLE OF CONTENTS

TABLE OF CONTENTS 1

SECTION ONE: CAUSES AND CONSEQUENCES OF INCIDENTS 2

SECTION TWO: STATISTICS 3

SECTION THREE: COSTS OF ACCIDENTS 4

SECTION FOUR: PROBABILITY AND LIKELIHOOD 5

SECTION FIVE: MANAGEMENT 6

SECTION SIX: DEFINITIONS 7

SECTION SEVEN: CONTROLLING POTENTIAL INCIDENTS 9

SECTION EIGHT: INCIDENT CAUSATION THEORY 11

SECTION NINE: CAUSATION MODEL 12

SECTION TEN: IDENTIFY THE ABSENT OR FAILED DEFENCES 15

SECTION ELEVEN: IDENTIFY THE INDIVIDUAL / TEAM ACTIONS 16

SECTION TWELVE: IMMEDIATE CAUSES 19

SECTION THIRTEEN: IDENTIFY THE TASK / ENVIRONMENTAL CONDITIONS (Underlying Causes) 20

SECTION FOURTEEN: MANAGEMENT CONTROL 22

SECTION FIFTEEN: RISK ASSESSMENTS 24

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SECTION ONE: CAUSES AND CONSEQUENCES OF INCIDENTS

WHY DO ACCIDENTS HAPPEN?
“Accidents don’t happen they are caused.” Many accident investigations reflect the lack of management control and subsequent
consequences. Where effective management control is lacking there are exposures in the work place. Safety in the work place is
managed by the imposition of policies, rules, regulation’s, standards, practices, procedures, systems of work, guidelines,
specifications and codes of practice.
Consider the following and their effect on maintaining a safe work place and systems of work:
Lack of leadership, lack of resources, urgency, poor training, lack of compliance, lack of roles responsibilities and accountabilities,
inadequate risk assessments and inadequate Job safety plans, inadequate or noncompliance with procedures, lack of
competence, production focus a priority, lip service to safety, superficial safety culture, no application of standards,
organisational culture, inadequate audits, inadequate inspections and reviews, inadequate contractor management and
oversight etc.
The failure to comply with systems of work and controls cause most of the incidents. Incident investigations enable the
identification of how and why these system failures occur, their consequences and what needs to be done to prevent
recurrence.

WHY INVESTIGATE ACCIDENTS?

By identifying the real causes, a similar or perhaps more disastrous incident may be prevented in future provided proper and
effective corrective measures are implemented.
Viewing the incident as "the consequence of a failure or inadequacy in the safety management system" engenders professional
investigative efforts. Identifying a failure in the system will assist with directing one towards uncovering meaningful information
regarding the incident.

CONSEQUENCE
Consequence essentially is the final outcome of an event. It is the collective sum of all the issues that the organisation will be
confronted with after the event, i.e. after the accident has happened. Consequences might be management intervention
strategies, reputational issues, restructuring, litigation, multiple fatalities, dismissals, official enquiry, prosecution, closure of
operation, shares devalued, fines, penalties and imprisonment, etc. The degree of severity would be relative to the measure as
determined by the organisation. It would relate to the number of people affected, the area affected, the magnitude of the loss
incurred and the degree of violation of statutory requirements and dependant on the view the judiciary would take given the
seriousness of the offence, etc.
BP agrees to pay largest penalty in US history in $4.5bn Gulf oil spill deal

Oil giant BP will pay $4.5bn to US authorities and agrees to plead guilty to 11 felony counts of misconduct over fatal rig
explosion.

BP has agreed to pay the largest criminal fine in US history – $4.5bn – to resolve all criminal charges arising from the fatal oil rig
explosion and catastrophic oil spill in the Gulf of Mexico.

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SECTION TWO: STATISTICS

FRANK BIRD STUDY: THE ACCIDENT PYRAMID
In order to understand the history of incident prevention, one needs a good understanding of what it takes to reduce injuries.
The accident pyramid model used many years ago will provide some useful information and assist with understanding.
In 1969, a study of industrial accidents was undertaken by Frank E. Bird, Jr., who was then the Director of Engineering Services
for the Insurance Company of North America. He was interested in the accident ratio of 1 major injury to 29 minor injuries to
300 no-injury accidents first discussed in the 1931 book, Industrial Accident Prevention by H. W. Heinrich. Refer to Figure 1.

Figure 1: Safety Pyramid Developed by H.W. Heinrich (1931)

For every reported major injury (resulting in fatality, disability, lost time or medical treatment), there were 9.8 reported minor
injuries (requiring only first aid). For the 95 companies that further analysed major injuries in their reporting, the ratio was one
lost time injury per 15 medical treatment injuries. Refer to Figure 2.

Figure 2
In 1993 the Health and Safety Executive (HSE) group of the British government published the results of one of its studies. The
study was conducted by a team of professionals, including economists, who visited five different locations representing different
industry types.
Other interesting findings of the British research include:
 37% of an organisation’s annual profit was lost due to incident costs.
 The equivalent of 8.5% of organisation’s total annual revenue was lost due to incident costs.
 The equivalent of 5% of an organisation’s operating budget was lost due to incident costs.
 Although there was a wide range of immediate causes for the incidents, there were very common underlying causes.
 A separate analysis of 80% of the incidents showed that over 8% had the potential to have serious or major
consequences.
Considering these studies, it is evident that there is a fundamental relationship between major incidents, minor incidents, and
near-misses. This infers that efforts directed at events where there is no consequence are more effective than focusing primarily
on serious incidents. Focusing on consequences is reactive not proactive.
Evidence suggests that there are more minor incidents than serious incidents in the work place. This confirms the merits of
giving attention to the less serious incidents so that the causes can be identified and corrected before more serious incidents
occur.

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SECTION THREE: COSTS OF ACCIDENTS

There is a direct relationship between direct costs (1) and all the hidden costs (6-53) that arise at a later stage that are not
immediately noticeable when an accident occurs. The costs of incidents can be illustrated as an iceberg, illustrated above.

The relatively low costs associated with insurance and medical expenses are obvious, like the tip of the iceberg, while the
enormous overall costs of incidents are to be found below the surface.

It will be noticed by reviewing the iceberg that for every 1 unit of costs, there are 6 to 53 times that amount of loss due to
property, environment, assets, reputation, process, material, and miscellaneous cost.

These numbers have been derived by researching insurance cost data which supports that the costs of losses reported in the
transportation industry (e.g. trucking and railroad), and various manufacturing industries alone is many times the national costs
of work related injuries and illnesses.

In addition, there have been numerous case studies, involving single sites or companies, which have since been done, which
support these numbers as well. For capital-intensive operations the costs tend to be high; whereas for labour-intensive
operations they tend to be relatively low. These costs must be carefully monitored or they will go unnoticed.

There are various costs associated with incidents. Some are obvious while others are less obvious such as:

Business opportunities foregone

Corporate brand, image and reputational issues
Criminal prosecution
Employee morale and commitment
Future leverage opportunities
Investigation and inquiry costs
Loss of investor confidence
Market share loss
Pain, suffering and anguish
Psychological trauma on employees
Public relations

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Costs can broadly be categorised under the following headings:

Compensation and
Operational costs Miscellaneous Legal/Litigation Process/Production
Benefits
Attorney and legal
Death benefits Capital expenditures Advisory fees Cleaning materials
counsel fees
Equipment Hired plant and Fines, penalties, and Defect production
Long term disability
replacement machinery costs citations costs
Loss of customers
Medical and
and returned Labour hire costs Labour/Union costs Equipment repair
rehabilitation
products
Pension benefits and Process / downtime
Marketing Settlements Laboratory costs
lump sum payments and loss
Rental costs for
Wages for hired Subject matter
replacement PR Management time
labour experts
equipment

Facility recovery Outsourcing Third party claims Overtime

Start-up costs Investigation fees Prosecution Retraining

Product recall Salvage and clean-up

Material recovery

SECTION FOUR: PROBABILITY AND LIKELIHOOD

Likelihood is the hypothetical probability that an event that has already occurred would yield a specific outcome.

The concept differs from that of a probability in that a probability refers to the occurrence of future events, while likelihood
refers to past events with known outcomes. I.e. it has happened in the industry or company before.

These factors affect the degree of likelihood of an occurrence of an event.

The probability of loss occurring whenever a particular task is performed is determined by the following factors:

Hazardousness (i.e. how inherently dangerous is the task).

Difficulty (i.e. is the task prone to quality, production or other problems?)
Complexity of the task.
The chance that loss will be incurred if the task is performed improperly.

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SECTION FIVE: MANAGEMENT

INTRODUCTION
World class organisations have established core fundamentals related to safety, one of which is that safety is a line management
responsibility. This “philosophy” is entrenched in PDO HSE management responsibilities. This infers that top management is
responsible for the overall establishment, implementation and maintenance and ultimately the performance of the safety
management system. This begs the question “Who is Management?”

MANAGEMENT
Given that people are generally involved in incidents, either directly or indirectly, it is appropriate that one understands the term
‘Manager’. Managers are responsible for managing organisational system processes and it is the failure of these management
system processes that needs to be identified.

Managers are the people responsible for enabling an organisation to achieve its stated goals and objectives.

Managers are responsible for the process of planning; organising; leading, coordinating and controlling the efforts of
organisational members and using all organisational resources at their disposal to achieve stated organisational goals. (Mescon
et al., 1985)

This explains what managers do:

Managers require skill and this management skill is explained as “getting things done by other people” (Parker Follett, 1941).
Furthermore, it can be said that the activity of management is “the process of optimising personal, material, and financial
contributions for the achievement of organisational goals” (Mescon et al, 1985).

WHAT MANAGERS DO
Fayol defined the following management functions:

Planning: the activities necessary to ensure the achievement of the stated organisational objectives
Organising: to ensure the availability and coordination of the material and personal resources within the organisational business
units necessary to accomplish the organisational goals
Leading: providing direction to employees
Controlling: involving the process of monitoring and adjusting organisational activities in order to facilitate the accomplishment
of organisational objectives
Coordinating: ensuring the organisational resources and activities work together to achieve stated goals.

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SECTION SIX: DEFINITIONS

MEANING OF INCIDENT

An unplanned and undesired event or chain of events that has, or could have, resulted in injury or illness, damage to assets,
the environment, company reputation, and/or consequential business loss.
or
the release or near release of a hazard, which exceeds a defined limit or threshold limit value.

MEANING OF MAJOR INCIDENT

Unplanned event which does result in injury, harm and damage

MEANING OF HIGH POTENTIAL INCIDENT (HiPo)

An Incident or unsafe/unhealthy condition or near miss where the most serious probable outcome is a Major Incident.

A HiPo may not be identified as such at the time of the Incident and it is only after investigation that the true severity of the
most serious probable outcome becomes clear. If, after investigation, an incident is found to fit these definitions, it should be
reported as a HiPo, even if it is outside the nominated reporting timeframe

It is critical that one understands the characteristics of an accident if one is to prevent them from occurring again.
For an accident to be an outcome of an event there has to be damage of some degree. If a person cuts his/her finger on a paper
cutter it is an accident. As minor as it may be, an injury is sustained. Where a serious incident occurs resulting in severe injury,
illness, harm or damage there has to be some contact with a source of energy or substances which exceed the resistive limit of
the body, structure or environmental media.
Energy is found in different forms such as chemical, electrical, thermal, kinetic, noise, radiation and potential energy, etc.
(page13)

The following examples illustrate an accident:

An electrician and his assistant were assigned the task of repairing a three phase supply to a pump station. The electrician
wanted to determine if there was supply on the load side of the distribution point and attempted to test one of the phases in
the main circuit breaker. In so doing he placed the tip of the probe of the multimeter between two of the phase lugs causing a
short circuit and a flash over. The consequence was serious burn injuries and a burnt out MCB.

The driver of a bulk fuel tanker fell asleep behind the wheel, resulting in the vehicle capsizing and spilling the contents of three
of the compartments, thereby contaminating the soil and resulting in a fire and fatality.

It is clear from the above that one incident is more severe than the other.

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MEANING OF NEAR MISS

An unplanned event that did not result in injury, illness, or damage to assets, the environment or Company reputation – but
had the potential to do so.
Or
An incident which under slightly different circumstances could have resulted in injury, harm or damage.

A near miss is an event where there is no undesirable consequence or outcome, i.e. no injury, harm, damage or illness is
sustained. It is typically an event where had there been a minor variation in circumstances the event would have resulted in an
accident rather than a near miss. Where these events occur one must consider the possibility of the outcome having been worse
and consider the worst case scenario. Where the potential exists for the consequences to have been severe one should
investigate the incident as if it had occurred and resulted in the worst possible outcome.

MEANING OF UNSAFE ACT/CONDITION

Any departure from the required or expected performance or condition of equipment (Plant), procedures (Process), or People
(conduct), which if not addressed could result in an Incident, or make a consequence of an incident more severe.

MEANING OF LOSS

Loss in environmental terms may be defined as “avoidable waste of a resource.”

Loss in terms of safety is defined as “avoidable harm to people, the environment, assets, reputation, systems and process”.

MEANING OF SAFETY

Control of accidental losses to an acceptable level

Judgement of the acceptability of risk
The minimisation of loss

MEANING OF CRITICAL FACTORS:

Negative actions or undesirable conditions that influence the course of events.
Major contributions to the incident. How did this event cause the incident. Why?
Actions or conditions, which if eliminated, would have either prevented the occurrence or reduced its severity.

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SECTION SEVEN: CONTROLLING POTENTIAL INCIDENTS

PHASES
When one conducts an investigation into an accident and determines the time line of events prior to the critical event occurring
that resulted in an accident one realises that there were contributing factors prior to the critical event occurring, the critical
event itself and post event issues i.e. consequences and emergency response etc. The accident investigation focuses on all the
evidence supporting events leading up to the critical event.

Compressor within the Tedlar unit malfunctioned

unit was restarted without the compressor

tested for flammable vapour concentration

area around the top of the slurry tanks
on the flash tank overflow line had a
Discovered that the U-leg seal loop

Lockout card completed for tank 1

Contractor performed the grinding
and welding repairs atop tank 2
The valves on the tank 1 fill and
discharge lines were locked out

“fishmouth” split in the pipe

Damaged agitator discovered
Slurry tanks were locked out

Hot work permit completed

Internal inspection tank 2

Tedlar process restarted

Slurry pumped out of
Process shut down.

tank 2 and 1
October 21

November 9
November 1
October 22

November 1

November 3

November 3

November 8
November 6
November 7
October 29

11.04
9 am

am
Welding sparks
Crew started work enter vessel Explosion
(critical event)

The Phases of control are explained by reference to pre-contact, contact and post contact control opportunities.

Therefore:
 Pre-contact control; offers opportunities to safeguard against the occurrence of the event,
 Contact control; offers opportunities to minimise the severity of the impact, and
 Post contact control; offers opportunities to safeguard against additional losses and mitigate “to make less severe” the current
circumstances.

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CONTROL AT THE PRE-CONTACT PHASE

In the pre-contact phase one needs to consider the effectiveness of implemented “barriers” and “defences” which are the
physical and procedural control processes such as policies, rules, regulations, standards, engineering practices, procedures,
systems of work, legislation etc. These control processes are necessary to minimise the threats, system or equipment failures,
i.e. latent or active failures, and should have evolved out of a hazard identification and risk assessment process.

CONTROL AT THE CONTACT PHASE- BEFORE THE ACCIDENT

Control at this stage would require considering numerous options at one’s disposal in order to minimise the consequences of
any impact. What measures were taken to minimise the initial impact?

reducing the amount of energy used or released fire resistant suits and equipment
reducing rotational speeds separator pits and sumps
reducing flow rates engaging alternative energy sources or substituting with less
reducing high pressure to low pressure harmful substances

raising the flashpoint of substances use of non-flammable substances

reducing high voltage to low voltage reduction of toxicity exposure levels in substances or
materials
reducing thermal values
replacing manual labour operations with automated systems
reducing volumes of stored chemicals
modify contact surfaces
placing barriers at point of exposure
install anti slip tread material
access control
install bollards
bunding
roughen surfaces
cages
smoothing edges
explosion bunkers
strengthening body or structure
fire walls
reinforcing structures
fume cupboards
case hardening of tool parts
machine enclosures
reinforce glass with film shield protection
machine guarding

CONTROL AT THE POST CONTACT PHASE – RECOVERY AFTER THE ACCIDEN T .

The extent of any loss can and should be controlled to ensure that the loss does not escalate into an uncontrolled state
resulting in even greater loss. For example, a fire in a gasification plant in a refinery needs to be contained otherwise the end
result could be devastating. This control should ideally be achieved by means of proper crisis management or emergency
response procedures and standards.

This might include amongst other things:

Appropriate training Medical response teams and facilities

Back-up equipment (e.g. pumps, foam systems, Proto teams
generators, lights, etc.) Rescue equipment
Disaster management plans Scenario drills
Emergency control facilities Spill prevention and control
Emergency response organisations Well-developed emergency response/crisis management
External support plans and procedures.

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SECTION EIGHT: INCIDENT CAUSATION THEORY

The purpose of accident investigations is to identify those direct and underlying causes that lead to accidents.
The ICAM system used here relates to SCAT “Systematic Causal Analysis Technique.” It is essentially a guide used to direct one
through the causation process systematically enabling one to identify the underlying cause of the problem.

UNDERLYING CAUSE
An underlying cause is an initiating cause of a causal chain of events which leads to an outcome or an undesirable effect of
interest. The term underlying cause is used to describe the depth in the causal chain where an intervention could reasonably
be implemented to change performance and prevent an undesirable outcome.

COMPONENTS OF UNDERLYING CAUSE ANALYSIS

PLANT/EQUIPMENT/MACHINERY/TOOLS/FACILITIES inadequate supervision

incorrect tool selection inadequate training or education
inadequate maintenance or design inadequate enforcement of rules
inadequate equipment or tool placement psycho social stress
defective equipment or tool METHODS
work environment inadequate procedures
disorderly workplace inadequate guarding
surfaces poorly maintained inadequate process
excessive physical demands of the task non-conformance practices (actions) with procedures
MATERIALS inadequate communication
defective raw material MANAGEMENT SYSTEMS
incorrect material for process inadequate systems
absence of raw material inadequate implementation
material not to specification inadequate compliance
MANAGEMENT inadequate roles and responsibilities
lack of or poor standard of management involvement inadequate standards
inattention to task inadequate recognition of hazards
inadequate work planning inadequate hazard identification and risk assessment

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SECTION NINE: CAUSATION MODEL

The causation model is a “tool” which enables one to follow a logical route necessary to determine underlying causes and
conclude a successful investigation. It represents the sequence or stages of events that lead to incidents and is a graphical
representation of the theory of causation.

The Incident Causation Model is best understood working from the loss section to the Risk Management and Compliance
section. This enables one to understand the sequence of events leading up to the loss. A diagram is used to facilitate a better
understanding of the relationship between the various aspects of causation as shown below.

For example, a loss was incurred due to a contact (the incident event) with an energy source or substance (hazard) due to a
failed barrier, (control) due to immediate causes, (unsafe acts/conditions) emerging from (basic) underlying causes produced
by system defects as a consequence of inadequate management control.

M ULTIPLE CAUSATION
Loss causation theory requires the understanding of the multiple causation theory which states that there are multiple causes
underpinning every incident. These multiple causes interact collectively to cause the incident. Once the causation sequence is
set in motion, it is unknown as to what the eventual outcome will be. This is best understood when one considers the domino
theory. If a number of dominos are aligned and the first domino is tipped, the rest will fall until the last one tumbles.

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LOSS
When an event happens in an organisation and the energies involved exceed the limitations of tolerance of a body or media to
resist the effect of the energy on the body often the consequences result in a loss. When a loss is incurred as a consequence of
an incident type event occurring it is termed an accident. These losses manifest (apparent) themselves in terms of injuries,
illness, harm and damage. They affect people, the environment, assets (tools, plant, equipment, machinery, materials) and
reputation, directly i.e. people are injured and become ill, the environment is harmed, and tools, plant, equipment, machinery
and facilities are damaged, thereby affecting process and reputation.

Harm to People: is the most serious of consequences and warrants the highest level of attention from Management.
There are tangible losses associated with injuries (such as trauma, disfigured bodies, compensation costs, rehabilitation costs,
absenteeism, overtime costs etc.) as well as personal costs (such as anguish, stress, suffering, psychological trauma, pain, poor
morale, etc.)
Harm to Environment: includes any negative impact on the environment that the organisation’s aspects may present
Harm to Assets: includes tools, plant, equipment, machinery, facilities, materials, and parts damage.
Harm to Reputation: is often overlooked, yet represents one of the most serious consequences that many organisations never
recover from. Consider that BP will never recover their reputation from the Texas City refinery explosion and Deep Water
Horizon disaster (Macondo Blow Out)

INCIDENT
The incident or potential loss-producing event immediately precedes the consequence. This is where the contact with a hazard
(unsafe act/condition, source of energy or substance) takes place. It is important to realise that there is the potential for an
undesirable consequence to occur and this will be dependent on the energies involved.
The term ‘potential loss producing event’ is used in this block because, at this point, the contact with energy or substance may
or may not be above the resistive limitation of the body, structure or environmental media that is exposed to this contact. If
the energy exchange is below the resistive limit of the body media or structure exposed, the incident sequence stops, i.e. no
harm, damage or injury occurs and the event results in a near-miss. If the resistive limit is exceeded, harm takes place and the
consequence is an accident. It is important to define the contact to assist one to understand the type of event that takes place.

Contacts can be classified into the following underlying types:

Caught between - in gears, belt rollers, rotating parts, drive bolts, chains, vehicles and trailers etc
Caught in - confined spaces, gears, pinch points, rollers, etc
Caught on - projecting or protruding objects, moving parts, etc
Caught under - object, material, equipment, plant, machinery, etc
Contact with - hot and cold surfaces, objects, materials or substances, toxic substances, energy sources, electrical sources,
chemicals, etc
Exposure to - toxic fumes, vapours, gasses, mists, extreme temperatures, ergonomic hazard, radioactive substance, noise,
chemical emission, etc
Fall from elevation to lower level - fall from ladder, platform, roof, stairs, scaffolding, structures, equipment, etc
Fall on same level - slip, trip, fall, etc
Handling - incorrect stacking, placing, storing, etc
Inundation - enter into water of unknown depth (drowning) or material in silos etc
Overstress - physical injury due to improper lifting, pushing, pulling, twisting, etc
Struck against - protruding objects, structures , etc
Struck by - mobile objects, vehicles, loads, etc

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T HE DIRECT CAUSE OF I N JURY

Whenever an injury occurs, a harmful level of energy is transferred to our body. We should describe the nature of that energy
transfer and refer to it as the direct cause of the injury.

Here are various forms of energy that could be harmful:

1. Acoustic energy - Excessive noise and vibration.
2. Chemical energy - Corrosive, toxic, flammable, or reactive substances. Involves a release of energy, ranging from "not
violent" to "explosive" and "capable of detonation".
3. Electrical energy - Low voltage and high voltage often described as “contact with.”
4. Kinetic (Impact) energy - Energy from "things in motion" and "impact," and are associated with the collision of objects in
relative motion to each other. It includes impact between moving objects, moving object against a stationary object, falling
objects, flying objects, and flying particles. Also involves movement resulting from hazards of high-pressure pneumatic or
hydraulic systems. This type of event is often described as “Struck by.”
5. Mechanical energy - Cut, crush, bend, shear, pinch, wrap, pull, and puncture. Such hazards are associated with components
that move in circular, transverse (single direction), or reciprocating motion.
6. Potential (Stored) energy - Involves "stored energy." Includes objects that are under pressure, tension, or compression; or
objects that attract or repulse one another. Susceptible to sudden unexpected movement. Includes gravity - potential
falling objects, potential falls of persons. Includes forces transferred biomechanically to the human body during lifting.
7. Radiant energy hazards - Relatively short wavelength energy forms within the electromagnetic spectrum. Includes infra-red,
microwave, ultra-violet, x-ray, and ionizing radiation.
8. Thermal energy - Excessive heat, extreme cold, sources of flame ignition, flame propagation, and heat related explosions.

L ET ' S TAKE A LOOK AT SOM E EX AMPLES DESCRIBIN G THE DIRECT CAUSE O F INJURY :

If a harsh acid splashes on our face, we may suffer a chemical burn because our skin has been exposed to a chemical form of
energy that destroys tissue.

In this instance, the direct cause of the injury is harmful due to a chemical reaction. The related immediate cause might be the
person working without face protection (unsafe behaviour).

If our workload is too strenuous, force requirements on our body may cause a muscle strain. Here, the direct cause of injury is
a harmful level of kinetic energy (energy resulting from motion), causing injury to muscle tissue.

If a person working at height (hazardous activity) trips and falls from height (event) and strikes the ground 8m below and dies
as a result of internal injuries sustained, the direct cause of the injury can be described as a result of “fall from higher to lower
level” the ground. The kinetic energy involved is due to the effects of gravity and exceeds to limitations of the body to absorb
the energy on impact.

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SECTION TEN: IDENTIFY THE ABSENT OR FAILED DEFENCES

These failures result from inadequate or absent defences that failed to detect and protect the system against technical and
human failures. These are the last minute measures, which did not prevent the outcome or mitigate the consequences of an
individual or team action that resulted in an incident or near miss.

The categories represent successive lines of defence where each defensive layer comes into operation on the failure of its
predecessor.

Defences in incident investigation:

Awareness To understand the nature and severity of the hazardous conditions present at the
worksite. Awareness problems reflect continuous shortcomings in those involved on-site
or those supervising and managing processes.

Detection To provide clear warning of both the presence and the nature of a potentially hazardous
situation.

Control and To restore people or equipment to a safe state with minimal injury or damage.
Interim Recovery

Protection and To limit the adverse consequences of any unplanned release of mass, energy or hazardous
Containment material.

Escape and Rescue To evacuate all potential victims from the hazard location as quickly and safely as possible.

The above model reflects the failed defences in the deep-water horizon (Macondo) incident.

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SECTION ELEVEN: IDENTIFY THE INDIVIDUAL / TEAM ACTIONS

These are the errors or violations that immediately precede the incident. They are typically associated with personnel having
direct contact with the equipment, such as operators or maintenance personnel. They are always committed ‘actively’
(someone did or didn’t do something i.e. they acted unsafely or failed to act i.e. an omission) and have a direct relation to the
incident.

For most of the time however, the defences built into our operations prevent these ‘human errors’ from causing harm.
Once again keep asking ‘why?’ someone acted (or was allowed to act) in the way they did or didn’t act the way they should
have leading up to the incident.

HUMAN FAILURE:
There are two main types of human failure:
1. Human error is an unintentional action or decision.
2. Violations are intentional failures – deliberately doing the wrong thing.

HUMAN ERROR
There are three types of human error: (skill-based errors)
1. slips
2. lapses
3. mistakes
These types of human error can happen to even the most experienced and well-trained person.

S LI P S AN D LA P S E S
Slips and lapses occur in very familiar tasks, which we can carry out without much conscious attention, e.g. using a grinder.
These tasks are very vulnerable to slips and lapses when our attention is diverted even for a moment.

SLIPS

Refers to errors in which the right intention or plan is incorrectly executed. Usually occur during well-practiced and familiar
tasks in which our actions are largely automatic.
Examples of slips include:
 performing an action too soon in a procedure, or leaving it too late, e.g. not putting your safety glasses or ear muffs
on before starting the machine;
 omitting a step or series of steps from a task, e.g. forgetting to connect the lanyard while refuelling the aircraft;
 carrying out an action with too much or too little strength, e.g. over-torqueing a bolt on a flange;
 performing an action in the wrong direction, e.g. a MEWP operator pushing the joystick to the left instead of the
right;
 doing the right thing but on the wrong object, e.g. selecting the wrong size wrench for the job; and
 carrying out the wrong check but on the right item, e.g. checking a pressure gauge but for the wrong value.

LAPSES

Refers to failures to carry out an action. Largely involve failures of memory.

‘Forgetting to do something, or losing your place midway through a task.’
Examples of lapses include:
 forgetting to tighten a scaffold transom;
 taking your safety glasses off to see properly and then forgetting to put them back on;
 failing to secure scaffolding because of an interruption; and
 forgetting to install an earth rod before operating a generator.
Slips and lapses occur when:
 people confuse two similar tasks;
 steps in a procedure don’t follow naturally;

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 tasks are too complicated and lengthy;

 the main activity is completed but the finer details are missed;
 the task is very familiar and requires little thought;
 there are too many distractions and interruptions.

MISTAKES

Mistakes are decision-making failures. The two main types of mistake are rule-based mistakes and knowledge-based mistakes.
They arise when we do the wrong thing, believing it to be right. Typically they involve deficiencies or failures in the judgement
process. More subtle, more complex and less well understood than slips and lapses and harder to detect.
Examples of mistakes include:
 making a poor judgement when overtaking, leaving insufficient room to complete the manoeuvre in the face of
oncoming traffic; and
 an operator misinterpreting the sound of a machine breakdown and failing to switch it off immediately.
Why do mistakes occur?
 doing too many things at the same time.
 doing too many complex tasks at once.
 time pressures.
Factors which contribute to people making mistakes
 the work environment – eg too hot, too cold, poor lighting, restricted workspace, noise.
 extreme task demands – eg high workloads, boring and repetitive jobs, jobs that require a lot of concentration, too
many distractions.
 social issues – eg peer pressure, conflicting attitudes to health and safety, conflicting attitudes of workers on how to
complete work, too few workers.
 individual stressors – eg drugs and alcohol, lack of sleep, family problems, ill health.
 equipment problems – eg inaccurate or confusing instructions and procedures.
 organisational issues – eg failing to understand where mistakes can occur and implement controls, such as training
and monitoring.
How you can reduce mistakes?
 To avoid rule-based mistakes, increase worker situational awareness of high-risk tasks on site and provide procedures
for predictable non-routine, high-risk tasks.
 To avoid knowledge-based mistakes, ensure proper supervision for inexperienced workers and provide job aids and
diagrams to explain procedures.

V I O LA T I O N S
These are intentional failures – ‘deliberately doing the wrong thing’. The violation of health and safety rules or procedures is
one of the biggest causes of accidents and injuries at work. Workplace rules are broken for many different reasons:
 “I felt I had no choice” – (intentional due to the situation or rules).
 “I wasn’t particularly concerned about the consequences” – (intentional violations).
Deliberate deviation from safe operating practices, procedures, standards or rules.
ROUTINE (corner cutting/ implicitly accepted).
EXCEPTIONAL (unusual circumstances).
DELIBERATE ACTS of SABOTAGE (damage intent).

Examples of violations include:

 scaffolders not clipping on their harnesses above 2 m;
 plant drivers not wearing seat belts;
 plant operators not carrying out pre-use safety checks;
 a site manager allowing untrained drivers to operate plant;
 a tradesman starting work on a new site without reporting to the site manager or receiving a site induction; and
 a worker thinking a rule is unsafe and taking off their safety goggles to improve visibility.

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Typical causes of violations include:

 a lack of understanding of why the rule is in place;
 being under time pressure;
 not having enough workers to do the work;
 not having the right equipment;
 peer pressure;
 perception that they won’t get caught;
 perceptions that rules are too strict or unnecessary – i.e. the perceived benefits outweigh the perceived penalties;
 wanting to take the easy option;
 workers thinking rules don’t apply to them;

How you can reduce violations

 Always think about the possibility of violations when carrying out risk assessments.
 Ask the workforce to get involved in changes to rules to increase their acceptance.
 Assess the use of personal protective clothes and equipment (PPE). Have workers got the right equipment to do the
job? Is the PPE difficult to use or uncomfortable?
 Encourage the reporting of any problems (such as job pressures) through open communication.
 Explain to workers the reasons behind any rules and procedures and their relevance.
 Improve planning for all jobs to ensure the necessary resources (workers, equipment, and time) are allocated.
 Improve the working environment. Is the environment unpleasant (e.g. dust, fumes, extreme heat or cold)? Have
workers got enough space to work in without discomfort or difficulty completing the task?
 Make sure rules and procedures are relevant and practical. Are procedures hard to read or out of date?.
 Provide training for abnormal and emergency situations.
 Provide workers with appropriate supervision.
 Try to reduce time pressures on workers to act quickly in unusual situations.
 You can increase the chances of spotting violations by increasing routine monitoring.

The following diagram shows the various categories used to classify human error, which are initially split into intended or
unintended actions.

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SECTION TWELVE: IMMEDIATE CAUSES

Every incident has a number of causes that happen immediately before the loss producing event. These causes are referred to
as Immediate Causes. Immediate causes are unsafe actions or unsafe conditions that take place or exist in the organisation.
They are typical violations of conformance requirements such as policies, rules, standards, legislative requirements,
procedures etc.

An important aspect of unsafe conditions is that one creates them; they don’t just appear out of nowhere. Unsafe conditions
are a result of people failing to take corrective action or failing to comply with the management process. An omission to attend
to something in the work place results in the creation of an unsafe condition, e.g. if one omits to maintain a piece of
equipment an unsafe condition is created. Furthermore these conditions are tolerated, permitted and allowed in the
organisation and the question must be asked why?? Unsafe practices are committed by individuals. They typically involve
omitting to comply with a predefined standard of performance or regulatory requirement.

If the immediate causes are not identified then the underlying causes cannot be identified and corrected. They, immediate
causes, are often called “unsafe acts” and “unsafe conditions”; however, a more acceptable term would be substandard
practices and substandard conditions. By referring to them as sub-standard it infers that there is a standard for these practices
or conditions and they are therefore manageable and in the realm of management control. Substandard practices and
conditions are indications that underlying problems exist within the management system. These underlying problems may
indicate that the system is inadequate, the procedures are inadequate, the standards are deficient, or there is no compliance,
etc.

Often organisations only look for immediate causes when investigating accidents and fail to investigate further, thereby
ignoring underlying causes and never resolving the failures in the system. The consequence is recurrence of the same events
with more dire consequences.

These underlying causes are influenced by the inadequacies in the systems of work and must be identified and corrected and
the necessary improvements made to the HSE management system. Section appendix A lists typical unsafe practices and
conditions, which directly cause incidents.

All relevant issues that were material in terms of the incident must be considered. Often it may appear as if the incident was
brought about due to the non-compliance of an individual and one is encouraged to stop there and look no further. This would
be futile as the underlying causes of his or her non-compliance must be identified in order for the management system
deficiencies to be addressed.

An important step is to ask, "Why?" Why did the individual not conform to the required step or process? This will lead one to
the actual underlying cause that precipitated the non-conformance.

Importantly when all the relevant evidence is collated and documented in the building blocks and the time line is “drawn” one
must determine which of this evidence is to be accepted as critical factors:

CRITICAL FACTORS
These factors are investigated to determine the underlying causes. They are typically the major contributing factors to the
incident without which the event would not have occurred or the severity would have been lessened.

1. Something which did not take place which should have taken place, i.e. an omission and if it had taken place it would have
definitely prevented the incident.
2. Something which took place which should not have taken place, and if it had not taken place the incident would definitely
not have occurred.
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SECTION THIRTEEN: IDENTIFY THE TASK / ENVIRONMENTAL

F ACTORS (U NDERLYING C AUSES )
These are the organisational factors or conditions in the work place in existence immediately prior to or at the time of the
incident. These are the conditions that directly influence human and equipment performance in the workplace. These are the
circumstances under which the errors and violations took place and can be embedded in task demands, the work
environment, individual capabilities and human factors.
The Task/ Environmental Factors can be categorised in two groups: Human Factors and Workplace Factors. Within the two
groups, we can categorise factors which encourage the commission of errors. The factors that can produce violations and the
common factors which may promote errors and/ or violations.

HUMAN FACTORS
Error Factors Common Factors Violation Factors

Preoccupation, distraction Insufficient ability Age and gender

Memory failure Inadequate skill High-risk target

Strong motor programmes Skill overcomes danger Behaviour beliefs

Perceptual set Unfamiliarity with task Subjective norms condoning violations

False sensations Poor judgement: illusion of control or least effort Personality: unstable extrovert, non-compliant

False perceptions Over confidence Perceived behavioural control

Confirmation bias Performance anxiety Low morale

Situational awareness Time pressures Bad mood

Incomplete knowledge Arousal state: monotony and boredom, emotional status Job dissatisfaction

Inaccurate knowledge Attitude to the system

Inference and reasoning Misperception of hazards

Stress and fatigue Low self-esteem

Disturbed sleep patterns Learned helplessness

Error proneness

WORKPLACE FACTORS

Error Factors Common Factors Violation Factors

Change of routine Time shortage Violations tolerated

Negative transfer Inadequate tools and equipment Compliance goes unrewarded

Poor signal/ noise ratio Poor procedures and instructions Procedures protect the system not the individual

Designer/ user mismatch Inadequate training Macho culture

Educational mismatch Hazards not identified Perceived license to bend rules

Hostile environment Under manning Adversarial industrial climate

Domestic problem Inadequate supervision Low operator pay

Poor communications Poor access to job Low operator status

Poor mix of hands-on work and written Poor housekeeping Unfair management sanctions
instruction (reliance on undocumented
knowledge)

Poor shift patterns/ overtime working Poor supervisor/ worker ratio Blame culture

Poor working conditions Poor supervisory example

Inadequate mix of experience/ inexperienced workers Task allows for easy short-cuts

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UNDERLYING CAUSES: HUMAN AND WORKPLACE FACTORS

Underlying (root) causes are the deeper basic causes, which initiate the immediate causes. In order to determine the
underlying cause one must consider the evidence and ask “how does this evidence support the underlying cause?” i.e. is there
a direct relationship between the underlying cause element and the evidence. For example, the evidence confirms that the
supervisor failed to comply with the procedure due to mental stress. The question that needs to be asked is whether this
evidence (a critical factor) has got anything to do with 3. Mental state. The answer would be affirmative. Thereafter one needs
to determine which sub element applies.
The underlying causes are classified under two main headings, namely Human Factors and Work Place Factors.

HUMAN F AC T OR S A R E T H O S E F A C T O R S , W H I C H A R E D I R E C T L Y A S S O C I A T E D W I T H T H E P E R S O N ( S )

They support the reason why a person acted the way he/she did. The following case study may illustrate the meaning of
Human factors and Work Place factors:
“An electrician attempted to isolate a high voltage switch and failed to lock out and earth correctly. He contacted 11 kva and
was badly burnt. One substandard practice would be failing to lock out. If queried as to why the person failed to lock out it
might come to light that he had not been trained and hence had no experience of the lock out procedure and the process of
locking out. This would mean lack of knowledge or experience is the Human factor. Inadequate training would be the Work
Place factor.

W OR K P L ACE F AC TOR S A R E T H O S E F A C T O R S W H I C H A R E D I R E C T L Y A S S O C I A T E D W I T H T H E O R G A N I S A T I O N A L
PROCESSES

In the scenario presented, it is very likely that there are other Work Place factors which may support the person’s practices
such as inadequate training, inspections, audits, reviews, communication, supervision, engineering standards, procurement,
tools or equipment etc.

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SECTION FOURTEEN: MANAGEMENT CONTROL

I NADEQUATE S YSTEMS C ONTROL – ORGANISATIONAL FACTO RS
Identify the Organisational Factors: These are the underlying organisational factors that produce the conditions which affect
performance in the workplace. They may lie dormant or undetected for a long time within an organisation and the
repercussions may only become apparent when they combine with the local conditions or errors or violations to breach the
system’s defences. These may include fallible management decisions, processes and practices.

ICAM classifies the system failures into Organisational Factor Types (OFTs) as follows:
Organisational Factor Types (OFTs)

CO Communication

CM Contractor Management

DE Design

HW Hardware

IG Incompatible Goal

MM Maintenance Management

MC Management of Change

OR Organisation

PR Procedures

RM Risk Management

TR Training

Sub-standard acts and conditions are preceded by underlying causes, however, they do not initiate the incident causation
cycle. The underlying causes manifest themselves due to the management controls being inadequate. These controls relate to
the safety management system and risk management enablers such as leadership, policy and strategy, people, resources,
governance, risk management process, compliance, supervision, inspections, maintenance, purchasing, contractor
management, planning, scheduling, reviews, instructions, investigations, corrective practices, communications, etc.

Effective management control is when all processes and procedures, established to ensure the organisation fulfils its
obligations are complied with. In order for the HSE system to be effective, a number of important criteria need to be met:

i. The safety management system must be well developed and thoroughly implemented
ii. Roles, responsibilities and authority must be assigned and accepted
iii. Policies, rules, regulations and standards need to be well established and understood
iv. Compliance with the requirements must be adequate
v. There must be suitable systems of work
vi. Key competencies must be deployed

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R OLES , RESPONSIBILITIES AND AUTHORITIES DEFINE :

 the work necessary to meet the organisation’s objectives
 who is responsible for the work to be performed
 who is accountable for what
 what specific actions are necessary
 the frequency with which these actions are to be taken
 who reports what to who, when

S AFET Y M ANAGEMENT S YSTEM

The effectiveness of any safety management system is dependent on the system’s design criteria. The design and
implementation of an organisation’s safety management system is influenced by:

i. Complexity of organisational activities;

ii. Established targets and objectives;
iii. Legislative, statutory, regulatory and other requirements;
iv. Organisational needs;
v. Organisation’s risk profile;
vi. Processes and operations;
vii. Products manufactured and services provided; and
viii. Size, structure and location of the organisation.

The system should typically be structured to accommodate the elements below:

COMMON MANAGEMENT SYSTEM FRAMEWORK HSE MANAGEMENT ELEMENTS:

LEADERSHIP AND ACCOUNTABILITY CUSTOMERS AND PRODUCTS

RISK MANAGEMENT ENVIRONMENTAL MANAGEMENT
SKILLS, TRAINING AND BEHAVIOURS (COMPETENCE) FACILITIES DESIGN AND CONSTRUCTION
ASSET INTEGRITY INCIDENT MANAGEMENT
BUSINESS CONTINUITY MANAGEMENT INFORMATION AND DATA MANAGEMENT
COMMUNITY AND STAKEHOLDERS AWARENESS MANAGEMENT OF CHANGE
CONTRACTORS AND SERVICE PROVIDERS OCCUPATIONAL HEALTH
CORRECTIVE AND PREVENTIVE ACTION SYSTEMS OPERATIONS AND MAINTENANCE
CORPORATE COMMUNICATIONS RECORDS AND DOCUMENTATION
CRISIS AND EMERGENCY RESPONSE MANAGEMENT ASSESSMENT, ASSURANCE AND IMPROVEMENT

CORE PDO HSE MANAGEMENT SYSTEM CP122 ELEMENTS

 LEADERSHIP AND COMMITMENT
 POLICY AND STRATEGIC OBJECTIVE
 ORGANIZATION, REPSONSIBILITES, RESOURCES, STANDARDS, AND DOCUMENTS
 HAZARDS AND EFFECTS MANAGEMENT
 PLANNING AND PROCEDURES
 IMPLEMENTATION AND OPERATION
 ASSURANCE – MONITORING AND AUDIT
 REVIEW

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SECTION FIFTEEN: RISK ASSESSMENTS

I NADEQUATE R ISK A SSESSMENT

Every organisation has to contend with risk in the work environment. OSHA states: “The employer shall make an evaluation
of the risk attached to any condition or situation which may arise from the activities of such employer.” This requires the
employer to conduct a risk assessment to quantify the extent of risk that has to be managed. This is the fundamental point
of departure for any safety management system. It involves understanding the exposures in the work place and
implementing control measures to safeguard against the risk. Hence the various elements of the safety management system
are the measures the organisation puts in place to safeguard its employees from the exposures. It is a process, which is
proactive.

The organisation should have a documented procedure established, implemented, and maintained for effective
identification of hazards, assessment of risks and implementation of appropriate management control processes to ensure
that risks are reduced to an acceptable level.

Furthermore they should consider all legal, statutory, regulatory and other requirements that the organisation is subjected
to.
Policies, plans and actions need to be developed

Targets and objectives need to be set against the background of the risk assessment and suitable action plans and programs
need to be assigned.

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APPENDIX A
COMMUNICATION
Failure to communicate when the target is known but the message fails to get through or is late. Involves inadequate
hardware and miscomprehension by those involved. Failure to validate understanding

Inadequate Communication can be caused by:

Inability to make contact with the correct person.
Lack of clear line of communication.
Language problems and cultural barriers.
Missing or excessive information.
No standard communication format.
Poor feedback.
Unreceptive or hostile target.

Inadequate Communication can lead to:

Missing information, people not informed, do not report.
Misunderstanding or incorrect interpretation.
Not knowing where information is located.
People not knowing who to inform.
Taking inappropriate action at the wrong time or place

C ONTRACTOR M ANAGEMENT
The evaluation, selection and retention of contracted services, equipment, personnel and material to ensure risks to people,
the environment, equipment or property are reduced to a level which is ARLAP.

Inadequate Contractor Management can be caused by:

Contract not clearly defining HSE obligations, performance and reporting requirements.
Inadequate or poorly conducted contract management process.
Inadequate or poorly conducted HSE compliance and performance monitoring and review.
Lack of clearly defined work scope.
Lack of consideration of risk associated with the contract.
Lack of formal contractor evaluation procedure.
Poorly defined selection criteria giving undue weight to cost over performance.
The failure to identify/ plan bridging requirements between the contractor and many standards.
Unclear reporting relationships, lines of communication, roles and responsibilities.

Inadequate Contractor Management can lead to:

Deferring, conflicting, or poor interface of procedures and systems of work.
Deterioration in production and safety performance.
Imbalance between contract compliance, production and HSE goals.
Lack of reporting of hazards, near misses and incidents.
Poor employee / contractor relations, industrial relations issues, high personnel turnover.
Requirement for additional supervision.
Risk levels above ALARP.
Substandard competency and staffing levels.

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D ESIGN
The way in which equipment is constructed to make certain operations difficult or allow unexpected usage. Poor design may
require extra effort and unusual maintenance. Inadequate design capacity may lead to extending the equipment beyond
limits. Many design failures result from the physical and professional separation of the designer and end user.

Inadequate Design can be caused by:

No standardisation of equipment or usage.
No adapting to human needs and limitations.
Poor designer-user communication.
Time or financial constraints.
No indication of system status provided by design (on/ off, working or not, etc.).
Inadequate design premise data.

Inadequate Design can lead to:

Extra effort to do the job.
Unexpected performance of tools and equipment.
Inability to operate equipment properly.
Inability/ difficulty in controlling processes.
Long or repeated training requirements.
Equipment is unused or improvised usage.

H ARDWARE
The quality, availability and position in life-cycle of tools, equipment and components. It’s concerned with the materials
selected rather than design or poor maintenance of the equipment.

Inadequate Hardware can be caused by:

Poor stock or ordering system.

Poor quality due to the local availability.
Poor state of existing equipment.
Inadequate maintenance
Equipment not fit for purpose.
Lack of resources available to buy, maintain or improve equipment.
Theft.

Inadequate Hardware can lead to:

Inappropriate use of tools or equipment.

Absence or unavailability of tools or equipment.
Improvisation, i.e. using tools unsuitable for the job.

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T RAINING
The provision and imparting of the correct knowledge and skills to employees which are necessary for them to do their job
safely. Failure may involve insufficient or too much training, lack of resources or assessment and mismatch of abilities to tasks.

Inadequate Training can be caused by:

Differing standards of training.
Ineffective pre-employment selection process.
Lack of appreciation of benefits
Making assumptions about a person’s knowledge or skills.
No assessment of training effectiveness.
Poor planning of when training is needed.
Training not directed to all the job skill requirements.
Training the wrong people.

Inadequate Training can lead to:

Employees unable to perform their jobs.
Excessive supervision.
Excessive time spent in training.
Increased numbers of people required for the job.
Job taking longer, of poor quality, wasting material.

O RGANISATION
Deficiencies in the structure of the organisation, lack of defined responsibility and inappropriate authority to current work.
May involve co-ordination, supervision of communication and feedback.

Inadequate Organisation can be caused by:

Excessive bureaucracy.
Frequent reorganisations.
Lack of definition of objectives.
No structure to co-ordinate different activities.
Poor planning.
Poorly defined departments or sections.
Unclear roles, accountability, authority, responsibility or delegation.

Inadequate Organisation can lead to:

Multi-layer hierarchy, slow response to changes.
Wrong person, or nobody, takes responsibility.
Resources used for non-business needs.
Decisions delayed or deferred.
People are only held responsible, not accountable for their actions/ decisions.
Poor control or management of events.
Rules and procedures not enforced.

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I NCOMPATIBLE G OAL
The presence of conflicts between production, safety, planning and economic goals as well as conflicts between group and
peer pressures and personal goals. Incompatible goals become a problem when senior management provide no guidelines on
priorities

Incompatible Goal can be caused by:

Conflict between appearance and functionality in a design.
Conflict between safe work and production priorities.
Conflict between work and personal priorities.
Imbalance between safety requirements and budget constraints.
Taking procedural short-cuts for personal / production gain.

Incompatible Goal can lead to:

Operating closer than normal to operating limits.
Overruling or relaxing procedures.
Putting people under pressure.
Short-cutting a procedure.
Suppressing information about hazards or injuries.

P ROCEDURES
The presence of accurate, understandable procedures which are known and used. Relates to the way in which procedures are
written, tested and documented and controlled.

Inadequate Procedures can be caused by:

Poor knowledge of the procedure writer.
Poor feedback on practicality.
Poor indexing or retrieval methods.
Gaps in the inventory of procedures needed.
Non-operational objectives (political/ organisational).
Failure to have revision control system.

Inadequate Procedures can lead to:

Ambiguous, non- comprehensive, incorrect or outdated documents.
Difficult access for the users.
No procedures for some specific tasks.
Too many, overlapping or conflicting procedures.
Failure to communicate existing or new procedures.
Documents in the wrong language.
Difficult procedures which encourage short-cuts
Toleration of violations

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M AINTENANCE M AN AGEMENT
The appropriateness of the management of the maintenance system, involving planning, resourcing and type of maintenance
rather than the execution of maintenance jobs. Poor practices, involving procedures, tools and training, are covered
elsewhere.

Inadequate Maintenance Management can be caused by

Absent/ inadequate manuals and documents.
Incorrect maintenance strategy.
Poor planning, controlling, execution and recording of maintenance.
Shortage of specialised maintenance personnel.
State of equipment not communicated to relevant people.

Inadequate Maintenance Management can lead to:

Breakdown before life expectancy.
Defective or malfunctioning equipment.
Equipment not operable in the way intended.
Makeshift or unplanned maintenance.
Unexpected rapid corrosion.

R ISK M ANAGEMENT
The systematic application of management policies, processes and procedures to the tasks of identifying, analysing, assessing,
reducing to ALARP (As Low as Reasonably Practical), and on-going monitoring of risk in man-machine systems that contain a
potential to have an adverse effect on people, the environment, equipment, property or the community

Inadequate Risk Management can be caused by:

Goals, objectives, scope and boundaries of risk management activity not clearly determined
Hazard identification process not being systematic, or covering all operations and equipment.
Inadequate monitoring of risk control effectiveness.
Inadequate or poorly conducted risk management process.
Inappropriate selection or poor implementation of risk measures.
Level of risk analysis (JSA, QRA, HSE Safety Case, etc.) inappropriate for the degree of risk or phase of lifecycle.
Risk assessment conducted without the appropriate competencies and experience

Inadequate Risk Management can lead to:

Risk levels above ALARP
Uncontrolled hazards and consequences
High incident and accident rate
Inappropriate risk ranking and allocation of risk control resources
Incomplete, inadequate, or out of date Risk Register
Breach of local regulatory requirements

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M ANAGEMENT OF C HANGE

The systematic assessment of change to operations, processes, equipment, services and personnel for potential risk and the
application of appropriate action to ensure existing performance levels are not compromised

Inadequate Management of Change can be caused by:

Inadequate monitoring of the effects of change to existing performance levels.
Inadequate or poorly conducted management of change process.
Inadequate risk vs. benefit assessment of the impact of change.
Inadequate tollgate mechanism to approve proposed change.
Objectives and scope of change activity not clearly determined.
Poor change implementation plan.
Poor communication of change

Inadequate Management of Change can lead to:

Adverse impact on production and safety performance.

Breach of local regulatory requirements.
Increase in equipment breakdown or damage.
Insufficient manning levels, confusion and low morale.
Mismatch between equipment, operating procedures and training.
Mismatch between policy, procedures and practice.
Risk levels above ALARP.
Undefined organisational structures and responsibilities.
Unexpected near misses, incident and accidents

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References
Cooke, David L. (2003). “Learning from incidents” (PDF). Proceedings of the 21st International conference of the System
Dynamics Society. http://www.systemdynamics.org/
conferences/2003/proceed/PAPERS/201.pdf
Davies, John; Alastair Ross, Brendan Wallace and Linda Wright (August 2003).
Safety management: A qualitative systems approach. London: Taylor and Francis. ISBN 0415303710
http://ehstoday.com/news/ehs_imp_32824/
Mescon et al 1985
Parket Follett, 1941
Henri Fayol
Hersey and Blanchard
Warren Bennis and Dan Goldsmith
Paul Birch
Patricia Pitcher
Bruce Lynn Industrial Accident Prevention, H W Heinrich
Rockwell Automation, Proving the value of safety, Justification and ROI of safety programs and machine safety investments, Lyle
Masimore, Rockwell Automation.
The Compass: Management Practice Specialty News, Why You’ve Been Handed Responsibility for Safety, J.J. Keller and
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Bird Frank E., Germain George L., Loss Control Management: Practical Loss Control Leadership, Revised Edition, Det Norske
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