Christel | Passionate About SHEQ Management

The Causes & Effects of Incidents

• August 17th, 2009

Causes of Incidents

Incidents can be generally defined as being the result of unsafe workplace conditions, acts, or poor decision making by someone in the chain of events. Statistics differ, but it is generally accepted that 20% of incidents are a result of poor workplace conditions and the remaining 80% are caused by some form of human error or non-conformance.

1. Technical equipment (machinery and tools)
2. Articles, materials and substances ( heavy, sharp, toxic)
3. Working environment (lighting, noise, temperature, humidity)
4. Human decision making factors and actions (acts, omissions, carelessness, negligence, errors of judgement, poor attitude)

A management system failure in one or more of these areas causes incidents.

Workplace conditions can be described as the general state of the workplace environment.

Although workplace conditions only form 20% of the causative factors, this is the area that needs the most attention. The reasons for first addressing conditions are that risks can be predicted and controlled. It is also far more cost effective to address conditions than to continuously control acts - i.e. human behaviour.

No matter how informed and competent people are, various factors influence day-to-day behaviour. The most reliable worker will at some time perform unsafe acts, or fail to follow correct and known procedures.
You will reduce opportunities for human errors by seeing that as many risks as possible are controlled by engineering standards.

Human errors are largely unpredictable. Even with the best information, training and monitoring  programmes in place, there will be a time when, for whatever reason, someone will fail to follow the correct steps and procedures.

Common factors that influence human behaviour usually result from one or more of the following deficiencies or errors:

Personal Factors

• Lack of knowledge, skill, or ability
• Physical or mental stress, imbalance or incapacity
• Poor attitude

Job Factors

• Poor purchase specifications
• Poor design and substandard conditions
• Inadequate maintenance
• Lack of or ineffective training
• Lack of work standards
• Lack of supervision and mentoring
• Substandard practices
• Failure to identify hazards and associated risks
• Poor or absent administrative controls.

The ANSI Code (Z16.2-1962 R1969) classifies unsafe acts and conditions as:

Unsafe Conditions

1. Inadequate guards or protection
2. Defective tools, equipment, substances
3. Congestion
4. Inadequate warning systems
5. Fire and explosion hazards
6. Substandard housekeeping
7. Hazardous atmospheric conditions (gases, dusts, mists, fumes, vapours)
8. Excessive noise
9. Radiation exposure
10. Inadequate illumination or ventilation.

Unsafe Acts

1. Operating without authority
2. Failure to warn or secure
3. Operating at improper speed
4. Making safety devices inoperable
5. Using defective equipment
6. Failure to use personal protective equipment
7. Improper loading or placement
8. Improper lifting
9. Taking improper position
10. Servicing equipment in motion
11. Horseplay
12. Alcohol, drugs or other substance abuse.

Effects

Incidents affect one or more of the following - individuals, organisations, clients, the general public, the community, and the environment.

The effects may be temporary or permanent and many can be identified immediately. Health and environmental effects may only become evident after a period of time.

SHEQ programme management is a pro-active process with the focus on containing risk by controlling hazardous conditions.

Well designed and executed inspections identify issues that are related to these causes.

Very closely related to this article is my article on Dominoes & Occupational Safety wherein I wrote about the late H W Heinrich’s Domino Effect.

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12 Responses to “The Causes & Effects of Incidents”

1. Dr John Anderson Says:
   August 18th, 2009 at 3:59 pm

   I have been in the construction health and safety business since 1970, and I do not accept for one moment your idea that workplace conditions only for 20% causative factors, and the remaining 80% are down to “human error”. Absolute TOSH. Grab Reason’s books on human error, and if you don’t know them then send me an e-mail.

2. Vijay Moodley Says:
   August 19th, 2009 at 12:49 pm

   Dear Christel
   I recently heard mention that only 10% of incidents are due to human error/non-conformance. This somehow ties up with my observations.In many cases if you proceed with the 5 why principle you find the basic root cause is due to workplace conditions or system deficiencies. i.e no/inadequate safe working procedures, culture of using untrained or barely trained persons etc., no risk assessments-scenarios that are triggers to the human non-conformance.
   Also, the above causes though valid and common, are not exhaustive. One should guard against designing incident investigation forms that utilise check boxes against these generic causes, to identify the cause/s of a specific incident.T hese often limit, and do not facilitate brainstorming of possible causes.

3. Juno du Plessis Says:
   August 19th, 2009 at 2:54 pm

   We are currently busy with a project to determine the reasons for a negative trend in occurrences at the mines in the Northern Cape. More info with regard to root causes of incidents would be welcome, especially the less visible like economic and social factors.

4. christel Says:
   August 21st, 2009 at 8:27 am

   Hi Vijay
   Thank you for the comment. I believe it is a generic method used by most to benchmark against. I do believe that there will be exceptions to the rule depending on nature and extend of the business as well as the amount of employees involved in the process. I value your comment greatly.
   Regards Christel

5. christel Says:
   August 21st, 2009 at 8:31 am

   Hi John
   We really appreciate constructive criticism and I would appreciate for the sake of the readers of this blog if you could provide us with your experienced knowledge and skill with a short write-up explaining your argument.
   Looking forward to hear from you.
   Regards Christel

6. said Says:
   October 19th, 2009 at 11:39 am

   Hi Christel,
   I find your blog very intersting. My opinion is that human errors count for approximately 80% of accidents causes i.e direct causes and indirect and basic ones in other words active failures that cause diretly the accidents and latent failures that are hidden untill they are triggered by some circumstamces/conditions.
   Regards

7. Christel Fouche Says:
   October 19th, 2009 at 12:30 pm

   Hi

   Thank you for your comment from so afar. Much appreciated to get an international comment. Regards Christel

8. KAREN KUWAZA Says:
   December 22nd, 2009 at 1:05 pm

   Hi

   I would like to know more about SHEQ i am currently studing Intergrated SHEQ Systems Standards and i am not sure what course i should do next for me to be a SHEQ Manager.

9. Christel Fouche Says:
   December 23rd, 2009 at 8:05 am

   Hi Karen
   There are so many choices. In general there are three distinct career path opportunities in this field: auditing, training and consulting. I am forwarding the career path steps to you. Regards Christel.

10. fanie oosthuysen Says:
    January 3rd, 2010 at 9:41 am

    Me aand my family work 8 to 10 hours a day with the general public with noiselevels @ 85 db +.We all suffer from mental stress and seek urgent help. 0832843275 Cape Town

11. Mark Esquino Says:
    January 27th, 2010 at 10:03 pm

    I have a different opinion regarding the stated 20 / 80 principal. Theoretically a workplace condition is directly due to the result of human based decision. With well implemented condition based monitoring, failure can be prevented. Granted that the decision made by human intervention is correct and actually applied. Looking at the listed examples of unsafe conditions; are they then not as a consequence of human error or violation. I have found that most times that there has ACTUALLY been an unsafe condition further possible consequence could have been prevented had the human influence been based on reduction of the risk as opposed to the level of severity. Conditions are based on a principal of mitigation of circumstances, consequently made by humans. I am of firm belief that the Reasearch, Development and Implementation of machinery used in the industry today is of an empecible standard. Obviously at a cost. Could we unhesitantly concur that the same costs are applied when it comes to the RDI of the atttitudes and behaviour of employees?
    Look at the success Du Pont have had internationally. Why, by addressing the focus on bahavioural aspects.

    Great website……….keep up the good work
    Mark

12. Christel Fouche Says:
    January 28th, 2010 at 7:46 am

    Hi Mark
    Thank you for the information. This is exaclty what we want with this website - a discussion about concepts between industry specialists. I want to emphasize your last question which I fully agree with: we have NOT applied the same costs when it comes to the RDI of the attitudes and behaviour of people. This is exaclty the underlying concern, but also the final success factor for a company who has control over their incidents. Thank you for the compliment. Regards Christel.

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