Slide #1.

RC-271 Safety Principles & Practices Accident Causation And Analysis
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Slide #2.

A Thought to Ponder ... “Prescription without diagnosis is malpractice, whether it be in medicine or management.” Karl Albrecht Organization Development
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Slide #3.

ILCI Loss Causation Theory  Inadequate MANAGEMENT control  Basic causes: personal vs. job factors  Immediate causes: substandard acts/ conditions  Near hit/accident: contact with energy, substance, and/or people  Loss: people, product, service, equipment, facility, and/or environment
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Slide #4.

THE ILCI LOSS CAUSATION MODEL LACK OF CONTROL BASIC CAUSES IMMEDIATE CAUSES ACCIDENT/ NEAR HIT LOSS Inadequate  Program  Program Standards Compliance to Standards  Personal Factors   Job Factors    Substandard Acts & Conditions    Contact With Energy, Substance or People    People Property Product Environment
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Slide #5.

Inadequate Management Control  A lack of internal standards designed to reduce/eliminate risks to loss  Hazard recognition and abatement  Performance appraisal  Employee/management communication  Internal standards are in place, but they are outdated or inadequate  Management and/or employees do not follow established internal standards
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Slide #6.

Basic Causes Job Factors Inadequate ...  supervision  engineering  purchasing  maintenance  tools/equipment  work standards Wear & tear Abuse or misuse Personal Factors Inadequate ...  physical capacity  mental capacity Excess ...  physical stress  mental stress Lack of ...  knowledge  skill Improper motivation
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Slide #7.

Immediate Causes: Substandard Acts  Operating equipment without authorization  Failure to warn  Failure to secure  Operating equipment at improper speed  Removing safety devices  Improper use of personal protective equipment  Servicing equipment in operation  Being under the influence of alcohol/drugs  Horseplay
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Slide #8.

Substandard Conditions  Inadequate guards/barriers  Inadequate personal protective equipment  Inadequate warning system  Fire/explosion hazard  Poor housekeeping  Noise/radiation exposure  Temperature extremes  Inadequate illumination  Inadequate ventilation
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Slide #9.

Near Hit/Accident  Struck by or against  Fall on same or to lower level  Caught in, on, or between  Contact with …..  Overstress, overexertion, or overload
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Slide #10.

The Loss People: People A bruise to a fatality Product: Product A dented package to a destroyed shipment Service: Service A few minutes lost to a month delay Equipment: Equipment A broken part to a destroyed machine Facility: Facility A cracked window to a leveled building Environment: Environment An air emission to contaminated groundwater 1
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Slide #11.

Basic Elements of a Near Hit/ Accident Reporting System  Develop agreed upon reporting standards  Routinely remind supervisors and employees of the need to report near hits & accidents  Maintain accurate records (computer-based)  Use data to identify accident/near hit trends  Routinely provide management and hourly employees with trend analysis results 1
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Slide #12.

Equipment for Collecting Near Hit/Accident Evidence  Flash camera w/extra film & batteries  Disposable  Digital  Camcorder  Tape measure  Grid paper 1
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Slide #13.

Importance of Immediately Gathering Perishable Evidence The 4 P’s of Perishable Evidence People: eople tend to forget or misrepresent Positions: ositions become altered Parts: arts get changed and/or discarded Paper: aper can become altered and/or lost 1
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Slide #14.

Initial Actions at Near Hit/Accident Scene  Take control (physical & emotional)  Provide first aid and call emergency services  Control potential secondary hazards  Identify sources of evidence  Preserve/gather evidence  Notify appropriate line/staff management 1
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Slide #15.

The Near Hit/Accident Analysis Process  Immediately collect the who, what, when, where, and how of the four P’s of evidence  Identify the loss and loss-producing event  Determine the most likely immediate cause  Perform an Ishikawa (e.g., cause-effect) analysis on the immediate cause  Test for most probable uncontrolled risk factors  Develop & implement control measures for at least 3 uncontrolled risk factors 1
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Slide #16.

Traffic Crash Scenario  Compact car approaches a stop sign  Motorcycle is approaching from car’s right  Driver of car pulls out in front of motorcycle  Motorcycle strikes car on right side  Cycle rider is killed instantly  Driver of car is severely injured 1
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Slide #18.

Traffic Crash Scenario  (cont.) Local law enforcement agency must perform an Ishikawa diagram to analyze the following major independent variables: Equipment  Processes/practices  Materials  Environment  People  1
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Slide #19.

THE ILCI LOSS CAUSATION MODEL LACK OF CONTROL BASIC CAUSES IMMEDIATE CAUSES ACCIDENT/ NEAR HIT LOSS Inadequate  Program  Program Standards Compliance to Standards  Personal Factors   Job Factors    Substandard Acts & Conditions    Contact With Energy, Substance or People    People Property Product Environment 1
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Slide #20.

THE ILCI LOSS CAUSATION MODEL LACK OF CONTROL BASIC CAUSES IMMEDIATE CAUSES ACCIDENT/ NEAR HIT LOSS Inadequate  Program  Program Standards  Personal Factors   Job Factors   Substandard Acts & Substandard Conditions     Compliance to Standards Contact With Energy, Substance or People    People Property Product Environment THE ISHIKAWA (FISHBONE) DIAGRAM Car enters cycle’s path (Caus e) (Effec t) 2
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Slide #21.

ISHIKAWA (FISHBONE) DIAGRAM People Equipmen t Procedure s Car enter s cycle’ s path Materials Environme nt 2
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