Dominoes & Occupational Safety
- June 18th, 2009
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 of a similar nature.
Examples include inaccurate risk assessments, poor purchase specifications, incompetence, lack of understanding of objectives of compliance, ill-health which interferes with proper performance, poor conditions, poor work standards, procedures and supervision and support, slow response times on works orders and maintenance, using incorrect tools, or using them in the wrong manner.
3. Immediate causes – can be traced to inferior standards and / or work practices
Acts, which are willful or negligent, or knowingly ignore set standards, will sooner or later result in an incident. Inferior standards are linked to conditions that do not meet recognised legal standards or codes of practice. Poor work practices refer to human acts as well as operating in uncontrolled risk conditions.
Examples include poor stacking, storage, obstructing exits, emergency equipment, and faulty equipment or damaged tools; as well as carrying out work in a way that endangers either self or others.
4. Incidents
An incident is an undesired and unplanned event which is outside of routine operations and accepted activities. It results in some form of loss – e.g. time, material, equipment, goods and also often causes human harm or suffering and / or environmental damage.
A common system failure results from only looking at the immediate causes of a near hit. “Near hit” should be investigated in exactly the same way as incidents. The direct and indirect causes need to be identified and actioned. Failing to do so will mean that the luck that prevented a loss this time will change. Good control of root causes prevents incidents. Ignore the warnings, and sooner or later you will have an incident.
5. Harm, damage, and some form of loss or business interruption -there are direct and indirect costs attached to all incidents
Even minor incidents incur costs – there is always a “price to pay” in one or more areas. Some costs are recovered – from insurers. But, the indirect costs are usually far higher than the recoverable costs. Accurate incident investigation reports that include full costing are excellent motivators for carrying out comprehensive investigations on all incidents. Remember that insurance premiums are in themselves a cost.
Other costs include time taken from normal duties to carry out or participate in an investigation; down time; equipment repair; material replacement; lower unit/volume output; lead time constraints, loss of market share; training of new staff / overtime / outsourcing; unable to meet family, social and community commitments and duties; rehabilitation of environmental damage; loss of fauna, flora or ecological breeding sites, etc.
The absence of an employee and family member leaves a gap in normal functionality and the ability to carry normal family and community responsibilities.
5 Responses to “Dominoes & Occupational Safety”
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Christel,
I absolutely like the formulation you use for “incident”. For us, the terminology has always been a problem since the OHS act refers to incidents as “something that causes an injury”. I agree with you in looking at “bear hits” also, since our injury count is very low, but our “near hit” count is much higher.
I have an interesting issue to put out there: Working in a R&D environment, there are some areas where there is little information available on risks. We try to predict some of the risks, and then act upon that prediction. However, quite often “incidents” happen where we never expected it, and in a few instances, we could not even explain it. (We had on incident where a chemical reaction ran away, and we could not duplicate this to find the reason for this.)
Now we end up with a root cause of “lack of knowledge”, but this is not a reflection on the system (the people are well educated and trained), not could this reasonably have been foreseen. In these cases, the only action is “reaction”. We attempt to add the learning to the project output, but in the end we always have risks we did not account for.
I would like to hear you comments on this.
Christel,
This is a different comment.
Your first domino refers to “control”. There are more than one control relevant here, and all equally important. The one I want to highlight refers more towards “engineering control”. In addressing safety systems, all to often we want to put all the emphasis on people control, with good reason, since people are the main cause of accidents. However, although under people control, we also have engineering controls. In a non-routine environment, we find that the amount of attention put on “people control” sometimes overshadows the amount of attention on “engineering controls”. This can easily cause a situation where the “person” assumes that the “process” controls are all in place, while sometimes they are not. (Agreed, “assume” points to a “person” root cause.) In non-routine applications, we always have to “assume” that the engineering controls are not properly in place, and have to be checked with more vigilance than in a routine application.
Hi Wynand
I fully agree – this is why pre-control risk assessments are so improtant and not only post-control risk assessments. This is also the reason why RA should be done as if NOTHING is in place – not even adequate engineering control.
Thank you for the input. Regards Christel.
Hi Wynand
Responding to the first comment. This would probably fall under the arguement of unforeseeable risks? These would alsways be re-active and very little will be in place to have addressed the risk once it happens. This is also why we believe knowledge is power and lately saying knwoledge and skill is power!! It is however scary that we cannot always predict everything and put measures in place. We can only try our best to save lives and improve workplace safety.
Regards Christel.
Hi Christel,
I personnally use an other definition which could be equivalent. I prefer to say that ” an incident is a sequence of events that may lead or may not lead to damages either to people, environment or facilities. When it leads to harms/damages I call it an accident. When it does not lead to harm it is a near miss”
Regards