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.
- Technical equipment (machinery and tools)
- Articles, materials and substances ( heavy, sharp, toxic)
- Working environment (lighting, noise, temperature, humidity)
- 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
- Inadequate guards or protection
- Defective tools, equipment, substances
- Congestion
- Inadequate warning systems
- Fire and explosion hazards
- Substandard housekeeping
- Hazardous atmospheric conditions (gases, dusts, mists, fumes, vapours)
- Excessive noise
- Radiation exposure
- Inadequate illumination or ventilation.
Unsafe Acts
- Operating without authority
- Failure to warn or secure
- Operating at improper speed
- Making safety devices inoperable
- Using defective equipment
- Failure to use personal protective equipment
- Improper loading or placement
- Improper lifting
- Taking improper position
- Servicing equipment in motion
- Horseplay
- 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.
18 Responses to “The Causes & Effects of Incidents”
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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.
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.
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.
Hi Juno
the incident analysis that you completed for the NC mines, what was the outcome and could you forward it to me.
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
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
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
Hi
Thank you for your comment from so afar. Much appreciated to get an international comment. Regards Christel
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.
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.
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
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
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.
I tend to agree but also disagree with your statement. I agree in terms of the 20/80 ratio but not that 20% of incidents are as a result of poor workplace conditions and 80% are caused by form of human error or non-conformances.
I am mid level career, 14 years in the construction industry and have successfully made a career out of OHSE management. And have work in some of the most inhospitable place in the world always aiming to protect the OHS of all employees on site, but what I have realized is that OHSE is a ball and chain that weighs people down in an otherwise productive environment, because in this day and age everyone is more concerned about covering their own ……… with all the legal requirements and paper work, instead of putting the necessary attention and detail into what is actually happening in their work areas of responsibility.
So in terms of the 20/80 principle I have found that if a change in mindset can be achieved with management (Foreman, supervisors etc.) that 80% of time rather be spend in the midst of construction activities and only 20% of time in an office then it is irrelevant of the site “conditions” that you would have a better working environment. Not all the world is on the same OHSE standards with major companies employing multi nationals from across the board, all with their own way of doing things but ultimately forgetting about the employee at the bottom who does not have all their degrees and university education. So I strongly believe in that if a work environment can be managed and controlled, then the cause and effect of incident would be less significant regardless of the actual site conditions or human behavior.
An example of this while doing building and construction work in the Philippines we made use of bamboo scaffolding, which by a long shot does not meet national or international standards, but we had not had one scaffold collapse or and employee falling from heights due to the working environment being managed and controlled – not to international standards but to standards that the local employees could understand and felt comfortable with. Thus we also cut cost of using “standard scaffolding” on the construction site.
So in conclusion, I know that majority of your readers and even yourself might disagree with my comment and statement but keep in mind (touch wood) in 14 years of construction I have not had one fatality or permanent disabling injury on any of the sites I have worked on because I exercise the principle of manage and control of the working conditions regardless of the working environment.
Kind Regards,
Willem
Hi Willem
Thank you for the detailed comment. In my opinion it always boils down to the human behavior aspect. If we could only change the behaviour of ALL employees and ESPECIALLY management to view safety as their own responsibility and not someone elses we would really have a safer working environment. Regards Christel.
The 20/80 priciple is but a principle. Mostly argued cause is the lack or inability by leadership/management to marry into SHERQ. I have been in the switchgear game most of my working live 22 odd years. I have seen firsthand management involvement. Normally short sighted and short focussed. I was the same at a time. Then I found out what the term: “I am my brothers keeper” means. Wake up people. Educate your staff and more importantly yourself. Lead (and manage) by example.
Christel, keep up this good work. Enjoy the critism. I do.
Hi Neil
Thank you for the valuable comment and of course I agree – I believe in garbage in, garbag out – the culture and belief of the CEO becomes that of the company. Regards Christel.
Over the years I have found there to be a significant change in the SAFETY in South Africa.Pre ’94 it appears that there was no significant need for SAFETY in SA as this was predominantly controlled by the political system of the time,ie APARTHEID. Post ’94 SAFETY has become a major concern and this SAFETY is not in refernce to compliance to any of the acts(OHS,MHS,ENv,etc) but instead financial safety.A concept derived from CAPITILIASM and blantly exploited in the giuse SAFETY or RISK. Mismanagement of SAFETY appears to be the single biggest loss in South Africa more especially on the projects where government is investing billions of rands on infrastructure development for ALL the people of SA.If a project is behind schedule,over budget and has a poor safety record, chances are a cabal has exploited and has had carte blanche to manupilate divisions such as engineering,procuement and even HR.
The 80/20 rule was established quite some time back and its principal has no bearing on what the present understanding is but instead it merely meant 80% of the budget goes to ME and 20% to YOU.