Causes and effects of accidents

The Risks and the Causes of Accidents
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VOF LCCB 2014
The filtering tower supports and guides the analysis of
undesired events and the construction of an adequate Loss
Control System. In the new paradigm of Loss Control we built a
Loss Control System from the inside out and we use the terms
“Accident Analysis” rather than “Accident Investigation”. The
aim of the game is ultimately to implement solutions derived
form the identified causes and not to blame the culprits! In the
new paradigm of Loss Control all members of the Community
work towards this goal. Only by this way, point 8 of Edwards W.
Demings’ program to survive the crisis – ‘Drive out Fear- will
become reality.
So one should use in the new paradigm of Loss Control only
those analyze models that do NOT put the blame on either the
workers OR management. The new paradigm needs models
through which management AND workers accept together their
responsibility to find the underlying real causes of the undesired
events. In the new paradigm there will be a tremendous shift
form “putting to blame” to “accepting from the inside out
accountability”.
Integrated Loss Control is aimed at the control of hazards, risks,
undesired events and losses. Therefor integrated Loss Control
deals in particular with the causes of those undesired events
and the minimizing of their effects. Indeed, as a cause is found
at the beginning of a realized loss, the risk is the origin of a not
yet realized loss. The main difference between a risk and a
cause is that the cause is an element of the past and the risk an
element of the present and the future.
Among the practical principles of professional Management is
the Principle of Multiple Causes:
This is an essential principle for Loss Control Management.
One should never assume that there is a single cause of an
accident or incident. And W. G. Johnson author of MORT
Safety Assurance Systems said that:
THE RISKS AND THE CAUSES
OF ACCIDENTS
1. Dynamic
Causes and
Effects Model
“Problems and loss producing events are
seldom, if ever, the result of a single cause”

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Experience shows that a majority of accidents involve
substandard practices, substandard condition and a
substandard organization of the workplace. And these are only
the symptoms. Behind the symptoms are the basic causes, the
deficiencies in the Loss Control System, the personal, technical
and organizational factors that led tot the substandard acts,
conditions and organization of the workplace.
It is good to keep in mind that, whilst we must try to identify
every possible cause of a problem, we should give the greatest
amount of attention to those with the greatest potential of loss
severity and the greatest potential of recurrence, so the
greatest risk! This is essential to effective Loss Control.
These principles will become clear using LCCB’s cause and
effect model. This Model is useful to find the different causes of
an undesired event. One should keep in mind that it is a model
and not the reality. A model is always a representation of the
reality and is needed in order to appreciatively understand the
reality and for deep communication with other (which is needed
for proper motivation for Loss Control).
“Undesired event will be caused by many
causes linked in a causal or temporal
sequence”.
Figure 1

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VOF LCCB 2014
In the following pages we will briefly describe the different
components of the model. Tough the model can be used in both
directions (top-down and bottom-up), thus proactive and
active, we have chosen for the pro-active presentation because
experience as taught us that this is the best way.
The following question can be the problem definition: How are
hazards transformed in losses? Or what is the sequence of the
risks (facts) that causes this transformation to happen? The
filtering tower gives a dynamic answer to those questions!
The metaphor we use for the Organization is a tower is placed
in the middle of an Archipelago of dangers and risks. One can
indeed see those dangers and risks as an archipelago of
icebergs that threaten the Organization. The Organization has
to protect herself against hose dangers and risks.
A lot of those are energies or products that causes losses
whenever there is a direct contact with a body or a structure.
The dangers are essential components of a situation or a
technical system. The dangers and risks that threaten the
organization are countless.
A very short list, by way of example:
 Raw materials and products (toxic products, combustibles,
explosives, radioactive components, …)
 Engergies (electricity, steam, thermal fluids, pressure
vessels, kinetic energy, …)
 Social/Human dangers (strikes, absenteeism, vandalism,
alcoholism, theft, …)
 Financial dangers (non payment of invoices, market
fluctuation, stock exchange fluctuation, price changes, …)
The definitions we use are:
The Organization has the responsibility to verify that the
arrangement taken by the concerned parties (suppliers) have
really diminished the risk at the acceptable level. If this is not
the case supplementary action has to be taken by the
Organization to lower the Risk under the acceptance level.
Danger and Risk
Archipelago
A Risk is the probability of (accidental) loss and it is what
rest of the Hazard after arrangements has been taken.
Hazard A Hazard is a situation or a system that has the potential to
cause losses.
Risk

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So the hazards and risks have to be treated adequately by the
Organization before they enter the Organization. The tower or
sometimes called ‘barrel’ is as been said a metaphor for the
Organization. This treatment of the hazards and risks is done
by the Management Loss Control System or shortly
Management System, since the control system is a
Management responsibility.
The system functions as a filter or sieve. The quality and the
functioning of this sieve are in fact responsible for the diking in
of those hazards and risk. The control system has three
subsystems that are closely interconnected (figure 3):
 Man: Personal Factors,
 Technique: Technical Job Factors
 Organizational: Organizational Job Factors

Figure 2
Figure 3

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The Personal Factors are Human factors of workers, staff
personnel and managers. The Technical Job Factors are linked
to the hardware aspects of the Organization and finally the
organizational focus on the organizational aspects of the
Organization.
Personal Factors
 Capability (Physical, Physiological, Mental and Psychological)
 Stress (Physical, Physiological, Mental and Psychological)
 Knowledge
 Skill
 Motivation
Technical Factors
 Engineering
 Purchasing
 Maintenance
 Inspection
 Tools and Equipment
 Excessive Wear and Tear
 Technical Hazard Analyze Process
Organizational Factors
 Leadership
 Safety System
 Contract Review
 Document Control
 Procedures/Instructions/Standards
 Control of Undesired Events
 Human Resources Management
 Accident Analysis System
 Technical Information System
If the Organization had the knowledge of all hazards and risks
and had the possibility to create an ideal Loss Control System,
it would weave a sieve with a quality wire and a constant mesh.
The dimension of the mesh would match the size of the
acceptable risks. In reality this ideal situation is not possible
since the Organization does not know all hazards and risks.
Therefor it is possible that non-identified risks enter the
organization (figure 4).

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The first sieve is a metaphor for as well the theoretical Loss
Control System as the functioning of that system at the
management level. As been said, this system is not perfect, on
one hand, some of the meshes are stretched out; on the other
hand, there are some holes in the system!
The size of the mesh reflects the quality of the Loss Control
System and has of course to do with the exact place of the iso-
criticality curve on the ‘pool of risks’. (Cf. Chapter 3 Risks).
Stretched out meshes mean that management does not
carefully for its own Loss Control System. Through the holes of
the first net not filtered dangers en risks enter the Organization.
This means that these are omissions and/or due to lack of
knowledge at the management level.
In the space under the first sieve or net one finds as well the
accepted risks as the non-identified ones! Both are the
responsibility of management.
Those risks will ultimately become the direct causes. They are
directly responsible for undesired events to happen. A second
sieve should capture those risks. This sieve describes the
quality of the treatment of those risks by the “reality of the
workplace”. That reality consists of the behavior of the workers
and their foreman, the physical conditions of the workplace and
the quality of the coach procedures and instructions. Those
three dimensions are strongly interconnected.
In case of not correct functioning of this sieve one speaks of
substandard actions, substandard conditions and a
substandard organization of the workplace. In case an accident
happens although the sieve is correct functioning this means
that the accepted risks are transformed into undesired events.
Figuur 4
Accepted and
Non-identified Risks

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By this we mean to say that there exist a right (standard) way of
doing things, right (standard) physical conditions and a right
(standard) organization of the workplace, so that the work can
be done without problems or undesired events – other than the
‘accepted’ ones.
Traditionally the substandard behavior identified was the
behavior of those who where directly involved in the coming into
being of the undesired event. This was - in case of an injury -
most of the times the victim. Nowadays those substandard
actions are linked to the substandard actions of other persons
earlier in the sequence, for example, those who have created
the substandard condition who is at the origin of the
substandard behavior.
How the second net looks like is given in figure 5.
We are using the following checklist:
SUBSTANDARD ACTS
1. OPERATINGEQUIPMENT WITHOUT AUTHORITY
2. FAILURE TO WARN
3. FAILURE TO SECURE
4. OPERATING AT IMPROPER SPEED
5. MAKING SAFETY DEVICES INOPERATIVE
6. USING DEFECTIVE EQUIPMENT
7. USING (SAFE) EQUIPMENT IMPROPERLY
8. FAILING TO USE PPE PROPERLY
9. IMPROPER LOADING AND PLACEMENT
10. IMPROPER LIFTING
Figuur 5

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11. IMPROPER POSITION FOR TASK
12. SERVICING EQUIPMENT IN OPERATION
13. NOT RECOGNIZING OR IMPROPER ASSESSMENT
OF A RISK
14. HORSEPLAY
15. UNDER INFLUENCE OF ALCOHOL AND/OR OTHER
DRUGS
SUBSTANDARD TECHNICAL CONDITIONS
16. INADEQUATE GUARDS OR BARRIERS
17. INADEQUATE OR IMPROPER PERSONAL
PROTECTIVE EQUIPMENT
18. INADEQUATE OR IMPROPER COLLECTIVE
PROTECTIVE EQUIPMENT
19. DEFECTIVE TOOLS, EQUIPMENT OR MATERIALS
20. INADEQUATE ERGONOMIC ASPECTS OF THE
WORKPLACE (lay-out)
21. INADEQUATE WARNING SYSTEM
22. POOR HOUSEKEEPING DISORDER (piles of
materials, housekeeping,...)
23. USED MATERIALS (chemicals)
24. FIRE AND EXPLOSION HAZARDS
25. NOISE EXPOSURE
26. RADIATION EXPOSURE
27. TEMPERATURE, MOISTURE EXTREMES
28. INADEQUATE OR EXCESS ILLUMINATION
29. INADEQUATE VENTILATION
30. HAZARDOUS ENVIRONMENTAL CONDITIONS
(gasses, fumes, dust, smoke, ...)
SUBSTANDARD ORGANIZATION OF THE WORKPLACE
31. LACK OF REFERENCE MANUAL ON THE
WORKPLACE
32. INCOMPLETE PROCEDURES, INSTRUCTIONS,
STANDARDS (P.I.S.)
33. INCORRECT P.I.S. (contradictions, inadequate
sequence of steps,...)
34. LACK OF CORRECT RULES AND REGULATIONS
35. LACK OF VISIBLE PRESENCE OF SUPERVISION
36. SUBSTANDARD CONTROL OF WORKPLACE
(measurement, evaluation and support of P.I.S.)
37. PLANNED INSPECTIONS NOT EXECUTED
ACCORDING STANDARDS
39. TASK ANALYSIS AND PROCEDURES NOT
EXECUTED ACCORDING STANDARDS
40. ACCIDENT/INCIDENT ANALYSIS NOT EXECUTED
ACCORDING STANDARDS
41. IMPROPER CONTROL OF COMPLIANCE OF
AGREEMENTS
42. LACK OF MOTIVATION/COACHING BY
MANAGEMENT

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43. PERSONAL PROTECTIVE EQUIPMENT NOT
AVAILABLE
44. COLLECTIVE PROTECTIVE EQUIPMENT NOT
AVAILABLE
45. CORRECT EQUIPMENT NOT AVAILABLE
Those three are interconnected. A substandard behavior,
dismounting the machine protection cover, can lead to another
substandard behavior: working at a non-protected machine.
The causes are even created at the level of the different sieves.
The not adequately applying of the engineering standards can
lead to substandard conditions, which can lead to substandard
behaviors, which ultimately lead to undesired events and
losses.
In the old paradigm accident investigation mostly stopped at the
direct causes. Once those were found and especially once a
substandard behavior was discovered the cause was found. In
other words the culprit was found and this was sufficient. And
this person was often the victim and almost always a worker.
Our model teaches us that there is more and that the risks must
be seen as symptoms of underlying causes (i.e. the not correct
functioning of the first sieve or the Loss Control System at the
Management Level). Therefor we call the direct causes
symptoms. By this we stress that they are not the real causes.
On the other hand the second sieve is not always functioning
correctly either The machines are not always well protected; the
personnel is sometimes fatigued and not alert and through
habitation does not see the risks anymore; the work instructions
are not updated in case of changes, etceteras.
Figure 6

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This sieve has - like the first one - also problems with stretched
meshes and holes. Therefor sometimes bigger risks are taken
than the accepted ones
At the level of the second sieve the mesh dimensions describe
the quality of the treatment of the risks. In case of increasing of
the mesh dimensions, the probability of the accident to happen
increases and/or the severity of the consequences increases.
The risks find more an opening in the sieve and this leads to the
undesired event, the undesired contact. The probability of an
undesired event with a certain consequence increases and thus
the risk. A real hole in the second sieve is a metaphor for an
omission or a lack of knowledge at the level of the workplace.
The workers and their front line supervisors have done a
mistake, have forgotten it or have never known it!
Under the second sieve we find the undesired events, the
contacts between an energy and a body or a structure. When
the second sieve is taken accidents and incidents will happen!
An undesired event is the mishap that causes the losses. It is
possible that the losses are minimal, due to the specific
circumstances, or even that there are no real losses. This is
the case of the mishap of a forklift that gets of the right track
and that misses a drum of extremely toxic chemical or just hits
the door so softly that there is no damage.
In those cases we call those undesired events near misses or
pure incidents. This does not mean that those events are
unimportant, not at all. Indeed, by correctly analyzing those
near misses we can prevent future losses to happen! Those
near misses are learning events. And by the way, in slightly
other circumstances (higher speed of the forklift, other place of
the drum, …) the event could have created losses, even big
losses (if the drum was severely damaged).
Undesired Events
Figure 7

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The undesired event is the event that precedes the losses – the
contact that could or does case the harm or the damage. When
risks of accidents are existing, the way is always open for a
contact with a source of energy above the threshold limit of the
body or the structure.
This source of energy can be kinetic energy, electric energy,
chemical energy, thermal energy, and etceteras. When the
energy transfer in that particular contact is above the threshold
limit of the body or structure, we call the undesired event an
accident, if not, we call it a near miss or an incident.
Here is a list of common types of energy transfers:
 Struck against (running or bumping into)
 Struck by (hit by moving object)
 Caught in (pinch and nip points)
 Fall to same or lower level (slip and fall, tip over)
 Contact with (electricity, heat, cold, radiation, caustics, toxic,
noise)
 Overstress/overexertion/overload
Those contacts are undesired events generate losses and even
after the contact there are still possibilities to minimize those
losses. These activities constitute the third sieve:
This third sieve is as you know not the best in Loss Control
although still very needed. In most cases an organization has a
theoretical correct sieve (at the Management level) to treat the
undesired events. This sieve consists of the reactive Loss
Control activities, not of the proactive ones. The latter are found
on the first and second sieve.
This sieve too has three dimensions: a human, a technical and
an organizational one.
Human aspects:
 Reporting of accidents
 Adequate reaction of people at the moment of the accident
 Quality of the rescue operations and first aid
 Adequate use of the equipment and resources
 Adequate transportation of the injured
 Human aspects of the medical treatment
 Rehabilitation of the injured
Technical aspects:
 Quality of the equipment and tools
 Distance between the scene of the accident and the First
Aid Room
 Speed of the reaction
 Technical quality of the medical treatment

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 Functioning of the technical safety devices in order to
minimize losses
 Repair and replacement of the damaged equipment and
other property damage
Organizational aspects
 Internal Communication Plan
 External Communication Plan
 Rescue Plan
 Medical Service Plan
 Procedure Restricted Work, adapted work
 Insurance’s
And also this sieve is not perfect either and has stretched
meshes and holes. Stretched meshes indicate for example the
not adequate execution of tasks during emergencies (due to
stress, pushing, …). A hole in the third sieves pictures an
omission or a lack of knowledge concerning the treatment of the
undesired event during the emergency (this as well by
managers as by other personnel).
Ultimately the undesired events, when they succeed in passing
‘successfully’ the last defense barrier, are transformed in real
losses. As you can see in Figure 7 the filtering tower or barrel is
closed at the bottom, this means that the losses have to be
absorbed by the organization!
Figure 8

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The results of an accident are losses. As reflected in our
definition the most obvious ones are harm to people, property
and process. The categories of losses are:
 People
 Motivation/Morale
 Material/Property Damage
 Environment
 Image
 Market
 Management
 People
Those people will be often own personnel and can also be
neighbors, clients and contractor personnel.
Nothing is more important or more tragic than the human
aspects of accidental loss:
 Injuries (first aid and doctor cases)
 Days away from Work injuries;
 Loss of body parts or functions;
 Fatalities;
 Occupational illnesses;
 Disability.
Not only physical, but also the psychological injuries (pain,
sorrow, anguish, …) are possible losses. In the new paradigm
of Loss Control one will take more care of the latter, non-
visible injuries than before.
 Motivation/Morale
The diminishing of the motivation and the moral of the
personnel due to too many undesired events is a loss that can
lead to less production, less quality, more absenteeism,
higher risk behavior, etc.
 Material
Loss of material: raw materials, products, contamination of
materials and end products, lower production quota,…
 Property
Property damage, material cost of repair and replacement of
parts, expenditures of equipment, …
 Environment
Losses due to the accidental burdening of the environment.
 Image
Loss of business an goodwill, adverse publicity, Legal suits
and expenses, …
 Market
Loss of orders, clients or market share due to loss of image or
product damage or product liability.
 Management
Loss due to the damage of the image of management. Loss of
goodwill of management at all levels.
Losses

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The Cause and Effect sequence visualizes top management’s
responsibility regarding the control of the underlying causes of
accidents. The need of management control is tremendous.
Without it the accident sequence begins and triggers the
continual causal factors that lead to loss. Without adequate
management control, the accident cause and effect sequence is
started and, unless corrected in time, leads to losses.
In the quality paradigm, Deming and others, stated that 80 to
84% of the causes of quality problems were to due to the
management control system. Accident Investigations of
numerous disasters underline the tremendous responsibility
and accountability of top management: The Herald of Free
Enterprise, the Challenger, The King Cross Fire, Piper Alpha,
Exxon Valdez, Heysel Drama, …
Management has to create its Loss Control System and the
standards of it. Management not only plans and organizes the
work to be done to meet those standards, it also evaluates
results and needs, commends and corrects performance. This
is the essence of Management Control. This is visualized by the
Deming cycle left to the filtering tower: PDCA!
This means too that management is responsible of continual
improving of the Loss Control System by adding system
activities and by specifying adapted standards or criteria.
Adequate standards are essential for adequate control. Lack of
compliance to those standards is a common reason for lack of
control.
Developing an adequate Loss Control System and standards is
an executive function, aided by supervisors. Maintaining
compliance with those standards is a supervisory function,
aided by executives. It is a management effort all the way!
Management
Responsibilities
Figure 9

Causes and effects of accidents

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