DKK 51423

INVESTIGATION
OF INCIDENTS

CHAPTER 7: INVESTIGATION
ANALYSIS
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DKKP, Kolej TESDEC 07/2018/Rev00
 ❖ Learning Outcomes ❖
• At the end of the lesson, students will be able to:
✓ Describe the theories involve in analyzing causes of an incident

✓ List the type of analysis available to determine surface causes.

✓ Describe the surface causes and hazardous condition.

✓ Describe each type of energy that are hazardous.

✓ Understand root causes and its forms.

✓ Describe the three levels of cause analysis.

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 INTRODUCTION
• The first step in conducting an analysis will generally
be the development of a detailed timeline.
• The goal of using a timeline during the investigation
is to structure events and actions in time accurately.
• Doing this helps the investigator to evaluate potential
causal pathways.
• After the timeline is (partly) developed there are
many models and methods available that can help
the investigator to analyse, structure and
communicate the findings.

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 

CONDUCTING EVENT ANALYSIS

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• After data collection
➢Turn that data into useful information.
➢To conduct an "assessment" to determine
what actors and acts were present.
➢To determine specifically how system
weaknesses interacted with those actors and
acts to cause the accident.

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 ❖ EVENT ANALYSIS ❖
❖Separation of an intellectual or substantial whole
into its parts for individual study
❖When there is a workplace accident, the
investigator need to separate or "break down"
the accident process (the whole) into its
component parts (events) for study to determine
how they relate to the whole.

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 ❖ EVENT ANALYSIS ❖

❖ Since the accident, itself, is the main event, its component

"parts" may be thought of as individual events leading up to
and including the main event or the accident.
❖ The accident investigator's challenge is to effectively assess
and analyze each event to determine if and how it
contributed to the accident.
❖ To do this we need to makes assumptions about what causes
accidents...why they happen.

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 ❖ Why accidents happen? ❖
Back to the basic theory:
UNSAFE
CONDITIONS
UNSAFE ACTS

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❑ Theorists realized that workplace accidents as
simple cause-effect events only.
❑ New theories explain the complicated interaction
among conditions, behaviors and systems that result
in an accident:
✓ Single Event Theory
✓ The Domino Theory
✓ Multiple Cause Theory
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 ❖ Single Event Theory ❖
• “Common sense" leads to this explanation.
❑Accident is the result of a single, one-time easily
identifiable, unusual, unexpected occurrence that
results injury or illness.
❑Some still believe this explanation to be adequate.
❑It's convenient to simply blame the victim when an
accident occurs

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 ❖ Single Event Theory ❖
❑ E.g. if a worker cuts her hand on a sharp edge of
work surface, her lack of attentiveness may be
explained as the cause of accident.
❑ALL responsibility for the accident is placed squarely
on the shoulders of the employees.
❑An accident investigator who has adopted this
explanation for accidents will not produce quality
investigation reports that result in long-term corrective
actions.
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 ❖ The Domino Theory ❖
• Describes an accident as a series of related
occurrences which lead to final event that results
injury or illness.
❖ Like dominoes, stacked in a row, the first
domino falling sets off a chain reaction of related
events that result in an injury or illness.

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 ❖ The Domino Theory ❖
❖ The accident investigator will assume that by
eliminating any one of those actions or events, the
chain will be broken and future accidents prevented.
❖The investigator may recommend removing the sharp
edge of the work surface (an engineering control) to
prevent any future injuries.
❖This explanation still ignores important underlying
system weaknesses or root causes for accidents.

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 ❖ Multiple Cause Theory ❖
• This explanation takes us beyond the rather
simplistic assumptions of the single event and
domino theories.
❖ Accidents are not assumed to be simple
events.
❖Accidents are the result of a series of random
related or unrelated acts/events that somehow
interact to cause the accident.

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 ❖ Multiple Cause Theory ❖

❖ Unlike the domino theory, the investigator will

realize that eliminating one of the events does not
assure prevention of future accidents.
❖Removing the sharp edge of a work surface does
not guarantee injury prevented in future.
❖Many other factors may have contributed to an
injury.
❖Recommend corrective actions together with
addressing the underlying system weaknesses that
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caused accident
 ❖ Multiple Cause Theory ❖

Identify root causes from the perspective of:

1. Human behavior
2. Job factor
3. Machine
4. Material
5. Plant
6. Operating system
7. Working procedure
8. Environmental surrounding
9. Management policy & commitment

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 ❖ Multiple Cause Theory ❖
Management tools can be use:
❑ Brainstorming
❑ Fault tree analysis
❑ Why, why, why, why, why.
❑ 5W 1H
❑ Ishikawa fishbone
❑ Pareto chart
❑ Bow tie analysis
❑ Tripod beta

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Fault Tree Analysis (FTA)

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Fault Tree Analysis (FTA)

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Ishikawa fishbone

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Pareto chart

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BowTie Diagram

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Tripod Beta

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 ❖ Developing the sequence of events ❖
• To accurately determine the sequence of events in the
accident process
• To effectively analyze the accident process.
• To study each event to determine related:
-Hazardous conditions. Things and states that
directly caused the accident.

-Unsafe behaviors. Actions taken/not taken that

contributed to the accident.

-System weaknesses. Inadequate or missing

programs, plans, policies, processes, & procedures

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• When the initial event occurs, it effects the
actions of others, setting in motion a potentially
very complicated process eventually ending in
an injury or illness.

• The trick is to take the information gathered and

arrange so that we can accurately determine
what initial condition and/or action transformed
the planned work process into an unplanned
accident process.

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• In the multiple-cause approach to accident
investigation, many events may occur, each
contributing to the final event.
✓if a supervisor ignores an unsafe behavior, the failure
to enforce behavior represents an event in the
production process that may contribute an accident.

• Each event in the unplanned accident process

describes a unique Actor and Action

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 Actor
➢ An individual or object that directly influenced the
flow of the sequence of events. An actor may
participate in the process or merely observe the
process. An actor initiates a change by performing
or failing to perform an action.
Action
➢ Something that is done by an actor. Actions may or
may not be observable. An action may describe
something that is done or not done. Failure to act
should be though of as an act in itself.

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 Sample sequence of events

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• It's important that the sequence of events clearly
describe what occurred so that someone who
unfamiliar with an accident is able to "see it
happen" as they read.
• If an event is hard to understand, it may be that
the description is too vague or general.

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• The solution: Increase detail. We can use two
strategies to increase detail:
➢Determine if anything else was said/done before
or after the event your currently assessing.
➢Separate actors.
➢Remember, an actor may be a person or a thing
accomplishing a given action.
➢If an event includes actions by more than one
actor, break the event down into two events.

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 It's important to understand that when
describing events, first indicate the actor,
then tell what the actor does. Remember,
the actor is the "doer," not the person or
object being acted upon or otherwise having
something done to them.

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 

SURFACE CAUSES OF INCIDENT

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 ❖ INTRODUCTION ❖

❑ After information gathered and

used to develop an accurate

Conduct an analysis
sequence of events.
of each event to
❑ After Get a good mental picture
determine causes.
of what happened.

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 ❖ TYPES OF ANALYSIS ❖

1.Injury
• Direct cause of injury
analysis
2.Event
• Surface cause of the accident
analysis
3.Systems
• Root cause of the accident
analysis

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 The hazardous conditions and
unsafe behaviors we identify as
contributing to the accident are
called the surface causes of the
accident.

Determine if inadequate safety

system components contributed to
the accident by allowing the ROOT
hazardous conditions and unsafe CAUSES
behaviors to develop or occur.

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 ❖ SURFACE CAUSES ❖
❖Hazardous conditions and unsafe employee or
manager behaviors
❖Have directly caused or contributed in some way
to the accident.

HAZARD

RISK

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 ❖ HAZARDOUS CONDITIONS ❖
➢ Are basically things or objects that cause
injury or illness
➢ May also be thought to be defects in a
process
➢ May exist at any level of the organization

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 ❖ Hazardous conditions may exist in:

o Materials
o Machinery
o Equipment
o Tools
o Chemicals
oEnvironment
oWorkstations
oFacilities
oPeople
oWorkload
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 ❖ Causes of hazardous conditions ❖
• Most hazardous conditions in the workplace are
the result of an unsafe behaviors.
• E.g.
➢ Omission & commission: actions we take or
don't take that increase risk of injury or illness
➢May also be thought to be errors in a process
➢May occur at any level of the organization.

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 ❖ Some example of unsafe
employee/manager behaviors include:
o Failing to comply with rules o Allowing unsafe behaviors
o Using unsafe methods o Failing to train
o Taking shortcuts o Failing to supervise
oHorseplay o Failing to correct
oFailing to report injuries o Scheduling too much work
oFailing to report hazards o Ignoring worker stress

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 ❖ Direct cause of injury ❖
➢ The direct cause of injury is not the cause of the
accident
➢ Each surface cause may somehow produce a harmful
level of energy
✓Transferred to our body directly causing an
injury
➢ The harmful transfer of energy is the direct cause of
injury

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❖ Harmful forms of energy may include:
• 1. ACOUSTIC ENERGY
➢ Excessive noise and vibration.
• 2. CHEMICAL ENERGY
➢ Corrosive, toxic, flammable, or reactive
substances. Involves a release of energy ranging
from "not violent" to "explosive" and "capable of
detonation".
• 3. ELECTRICAL ENERGY
➢ Low voltage (below 440 volts) and high voltage
(above 440 volts).

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• 4) KINETIC (IMPACT) ENERGY
➢ Energy from "things in motion" and "impact," and
are associated with the collision of objects in
relative motion to each other.
➢Includes impact between moving objects, moving
object against a stationary object, falling objects,
flying objects, and flying particles.
➢Also involves movement resulting from hazards of
high pressure pneumatic, hydraulic systems.

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• 5) MECHANICAL ENERGY
➢ Cut, crush, bend, shear, pinch, wrap, pull, and
puncture
➢Associated with components that move in circular,
transverse (single direction), or reciprocating motion.
• 6) RADIANT ENERGY HAZARDS
➢ Relatively short wavelength energy forms within the
electromagnetic spectrum.
➢Includes infra-red, visible, microwave, ultra-violet, x-
ray, and ionizing radiation.
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• 7) POTENTIAL (STORED) ENERGY

➢ Involves "stored energy." Includes objects that are under pressure,

tension, or compression; or objects that attract or repulse one another.

➢ Susceptible to sudden unexpected movement.

➢ Includes gravity and forces transferred biomechanically to the human

body during lifting.

• 8) THERMAL ENERGY

➢ Excessive heat, extreme cold, sources of flame ignition, flame

propagation, and heat related explosions.

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 ❖ EXAMPLES ❖
• 1) If harsh acid splashes on face, we may suffer a
chemical burn because our skin has been exposed
to a chemical form of energy that destroys tissue. In
this instance, the direct cause of the injury is a
harmful chemical reaction.
• The related surface cause might be the acid
(condition) or working without proper face
protection (unsafe behavior).

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• 2) If our workload is to too strenuous, force
requirements on our body may cause a muscle
strain. Here, the direct cause of injury is a harmful
level of kinetic energy (energy resulting from
motion), causing injury muscle tissue.
• A related surface cause of the accident might be
fatigue (hazardous condition) or improper lifting
techniques (unsafe behavior)

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• The important point to remember here is that the
"direct cause of injury" is not the same as the
“surface cause” of the accident.
• To summarize:
➢The surface cause of the accident describes
a condition or behavior. The result of the
condition and/or behavior is the direct cause
of injury...a harmful transfer of energy.
➢The direct cause of injury is the harmful
transfer of energy. The direct result is injury.

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• Safety "engineers" closely analyze all the
surface cause categories and attempt to:
❖eliminate the harmful energy,
❖reduce the harmful energy transfer, or
❖reduce exposure to harmful energy transfer.
• They do this by designing safety features directly
into tools, machinery, equipment, facilities, etc.

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 

ROOT CAUSES
OF INCIDENT

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 ❖ INTRODUCTION ❖
• The root causes for accidents are the underlying
safety system weaknesses that have somehow
contributed to the existence of hazardous
conditions and unsafe behaviors that represent
surfaces causes of accidents. These
weaknesses can take two forms:
➢ System Design Root Causes
➢System Implementation Root Causes

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 System Design Root Causes
• Inadequate design of OSH management system.
PRACTICES
PROGRAMS POLICIES

THE 6P
PROCESSES
PROCEDURES
PLANS

inappropriate conditions,
activities, behaviors, and “Surface
practices occur Causes” lead to
throughout the workplace. system design
flaws.

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 System Implementation Root Causes

• Inadequate implementation of OSH management

system

Failure
Effectively implement a No implementation of
poorly written safety OSH management
plan, system

need to improve one or more policies, plans,

programs, processes, procedures or practices

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• Safety managers work with safety engineers to:
➢ eliminate or reduce exposure to hazards
through effectively improving safety system
components
➢eliminating any single root cause may.
➢ simultaneously eliminate many hazardous
conditions and unsafe behaviors.

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• When analyzing for system weaknesses, it may
be beneficial to coordinate closely with those
who will be responsible for implementing system
improvements.

Upper management most likely

going to be involved in making the
necessary improvements

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 

SUMMARIES

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 ❖ Three levels of cause analysis ❖
❖ An accident may be the result of many factors
❖In an effective accident investigation, the
investigator will conduct three levels of cause
analysis:
▪ Injury analysis
▪ Event Analysis
▪ Systems analysis

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 ❖ Injury analysis ❖
➢ At this level of analysis, we do not attempt to
determine what caused the accident,
➢ We focus on trying to determine how harmful
energy transfer caused the injury.

• Remember, the outcome of the accident

process is an injury

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 ❖ Event Analysis ❖
➢ Here we determine the surface cause(s) for the
accident;
• The hazardous conditions and unsafe
behaviors described throughout all events that
dynamically interact to produce the injury….

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 ❖ Event Analysis ❖
➢ All hazardous conditions and unsafe behaviors
are clues pointing to possible system
weaknesses.

➢ This level of investigation is also called "special

cause" analysis because the analyst can point
to a specific thing or behavior

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 ❖ Systems Analysis❖
➢At this level we're analyzing the root causes
contributing to the accident.
➢We can usually trace surface causes to
inadequate safety policies, programs, plans,
processes, or procedures.
➢ Root causes always pre-exist surface causes

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➢ May function through poor component design to
allow, promote, encourage, or even require
systems that result in hazardous conditions and
unsafe behaviors.
➢ This level of investigation is also called "common
cause" analysis because we point to a system
component that may contribute to common
conditions and behaviors throughout the company.

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• The biggest challenge to effective accident
investigation is to transition from event analysis to
systems analysis
❑ Thoroughly conducting all three levels of analysis enable the
design of system improvements that effectively eliminate
hazardous conditions and unsafe behaviors in the entire
organization.
❑The accident investigation can not serve as a proactive safety
process unless system improvements effectively prevent future
accidents.

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 ❖ Example of Event Analysis ❖
▪ "Fishbone Diagram," used successfully to help conduct an
event analysis

1.Get a sheet of paper.

2.At the top of the sheet write "Accident Analysis". Doing this
reminds you that you're breaking down the process into a
number of events.
3.At the left side of the sheet, centered, write "The Injury".
4.Extend a horizontal line out from the right of the box.

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 5. Describe the injury event on the horizontal line.

6. Identify and circle the actors and actions described in the event
statement

7. Start asking why questions about the actor and actions to

uncover any hazardous conditions or unsafe behaviors.

8. Draw lines either angling up or down from the circled actors

and actions and write the answers to your questions. Repeat
these steps with each of the new level of answers.

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5/3/2023 DKK 51423 66
➢ Most accidents in the workplace
• result from unsafe work behaviors
➢Each level of questioning will get you closer to the
root cause(s) that allowed the hazardous condition or
unsafe behavior.
➢Once you start identifying inadequate policies,
programs, plans, processes, and procedures...you're
getting to the real root causes!

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 ❖ FINAL WORDS ❖
• According to the latest research:

➢ UNSAFE BEHAVIOR represent the direct cause for about 95% of all
workplace accidents

➢ Hazardous conditions represent the direct cause for only about 3% of

workplace accidents.

➢ "Acts of God" account for the remaining 2%.

• All these statistics imply that management system weaknesses

account for fully 98% of all workplace accidents. Accident
investigation must not end until the root causes have been identified.

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 References
• Reese, C.D. (2003). Occupational Health and Safety
Management: A Practical Approach, New York, Lewis.
• Goetsh, D. L. (2004). Occupational Safety & Health for
Technologists, Engineers, and Managers (5th ed), Upper
Saddle Rover, NJ, Prentice Hall.
• O’Donnell, P. & M.P.H. (2001). Health Promotion in the
Workplace (3rd ed), New York, Delmar Learning.
• Australia/New Zealand Standard 4801-2000 OHS
Management Systems
• Law of Malaysia: Occupational Safety and Health Act
1994(Act 514)

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 End of
Chapter 7
Don’t learn safety by
accident…

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