Dominoes & Occupational Safety

The late H W Heinrich used dominos to demonstrate the cause(s) and effects of workplace accidents (1959). This timeless model is still valid today - after more than 40 years.

The ripple effect of falling dominos demonstrates the need for a sequence of proactive steps to manage and control incidents. When one domino falls the rest follow - in a chain reaction that cannot be stopped once it has begun!

DOMINO SEQUENCE

1. Lack of control - is a sign of management systems failure

Inadequate or ineffective hazard identification and risk assessment and management; and / or inadequate standards; and / or degrees of non-compliance or non-conformance; are all indicators of inferior management and system failure. If all the necessary controls are not implemented and maintained in a consistent and disciplined way, workplace conditions, standards, procedures and attitude affects behaviour and increases risks.

Examples of controls would include competence, education and training, WSWP, JSA, operator checks, formal inspections, planned maintenance, purchase specifications, record, reports, reviews, etc.

2. Root Causes - the true origin or source of an incident

This term is synonymous with “underlying”, “basic”, or “indirect” causes. Root causes are linked to personal and job factors. These factors influence good performance. If they are not maintained at optimum levels, their negative influence will result in sub-standard conditions and unsafe acts that downgrade operations. It is essential that these factors are identified, analysed and evaluated for deficiencies. This is not always an easy task as many causes require in depth investigation and are not immediately or easily identified. The fact that there are usually several root causes makes identification critical to prevent a recurrence or future incident …

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Christel Fouche

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