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dc.contributor.authorJacinto, Celeste
dc.date.accessioned2016-12-12T11:45:23Z
dc.date.available2016-12-12T11:45:23Z
dc.date.created2016
dc.date.issued2016-12-12
dc.identifier.urihttp://hdl.handle.net/10630/12556
dc.description.abstract1. Scope & Objective Scope: The investigation of occupational accidents has long been a matter of discussion, mainly among specialists, but its translation into company practice has only registered real growth on the turn of the new millennium, essentially as a natural consequence of the H&S (Health & Safety) emerging management systems. In Europe, the many H&S Directives have also played a central role in this field by bringing about new requirements and creating new needs. This trend has boosted the development of new methods and tools designed to serve the goal of safety improvement. Objective: this is a thematic lecture aiming at communicating fundamental but important aspects of “accident investigation and analysis” (AIA). At the end, attendants are expected: a) to recognise the most important characteristics of any AIA method, b) to know where to find a variety of up-to-date methods that are aligned with modern safety management thinking, and c) to understand how to use AIA processes for promoting safety through organisational learning. 2. Basic definitions and terminology At the beginning of the session a few fundamental concepts are defined to ensure that all participants have a common understanding and interpretation of the terminology used. Formal definitions are provided for the terms “accident”, “near-miss”, “dangerous occurrence”, “investigation”, “analysis” and “learning”. In particular, the last three are hereby defined as: Investigation – means a search for factual accident data; implies a systematic search of the relevant facts; it is essentially about fact-finding and the identification of observable elements (raw data) (Jacinto et al, 2011). 1 Celeste Jacinto – thematic lecture on accident investigation and analysis Analysis – this concept holds the need to interpret data and to establish causal links; it implies the search for logical explanations rather than facts and events; a certain amount of information might be inferred (information) (Jacinto et al, 2011). 3. Models & methods of accident causation Attention is firstly drawn to the difference between “models” and “methods”, highlighting how the term “model” is used for theories that help explaining accident mechanisms, whereas “methods” are something more specific. These can be seen as a practical tool to help a user to perform a specific task. Models are usually more abstract, in contrast with methods that are much more specific. After a glance at several accident theories and a few methods considered relevant in this field, the attention goes to a specific process, called RIAAT, which was designed for the recording, investigation and analysis of occupational accidents. Models: this short review (Jacinto et al, 2011) includes a few models (theories) considered important “landmarks” in the domain. Domino theory, by Heinrich in 1931. Heinrich’s domino theory is now out of date and is now considered over-simple. However, it still has historical value and helps starting the debate on causation theories. It postulates that accidents result from a chain of sequential events, metaphorically like a line of dominoes falling over. Removing a key factor (such as an unsafe condition or an unsafe act) prevents the injury by interrupting the chain of events. Loss control model, by Bird in 1974. Bird proposed the first update of the domino theory. Fundamentally, it traces the root causes of accidents to failures in management ‘loss of control’ and has been a standard model of accident causation in manufacturing and industrial settings for decades. Energy model, by Haddon in 1973. The concept of “energy release” or “energy damage” emerged in the late 1960s by the work of William Haddon Jr. It postulates that in an accident, the injury (or damage) is caused by the transference of the Learning – encompasses the processes related to establishing new knowledge aiming to implement changes to, or gaining deeper comprehension of, and/or confirming the basis for current practices (Njå & Braut, 2010). 2 Celeste Jacinto – thematic lecture on accident investigation and analysis harmful energy (e.g.: mechanical, electrical, thermal, chemical, etc.), from its source to the person in “contact” with it. The various risk control strategies include both prevention (e.g.: to avoid the building-up of harmful energy) and protection (e.g.: implementation of barriers that minimize consequences). Therefore, this theory is implicitly linked to the concept of “barriers”. Deviation model, by Kjellén in 1978. This concept involves any abnormal event that ‘deviates’ from the established ‘norm’, i.e., from its planned and normal process (e.g., deviations in technical functions of machines, working procedures or instructions). Deviations can be searched for within technical, human and organisational functions, on the basis of work activities. The fundamental idea is that ‘deviations’ from the norm can represent a hazard. This approach was first introduced in Sweden by Urban Kjellén in the late 1970s for the post-analysis of occupational accidents. During the 1980s, it was adapted by Harms-Ringdahl for use in risk analysis in production systems. Incubation - Trigger Event Theory, by Turner in 1978. Turner’s model addresses the multi-causality aspect and explains accidents as the result of a combination of undesirable events, in which ill-defined safety problems will “incubate” for a period of time until a “trigger” event provokes or precipitates the accident. “Swiss Cheese” Model or the Model of Organisational Accidents, by Reason in 1990 and 1997. Reason traces accident causation from the “distal” (or latent) organisational factors, to local workplace conditions, which in turn combine with human factors, resulting in errors and violations, labelled as “unsafe acts”, which are the “proximal” causes of accidents. Some of these unsafe acts breach the system’s defences (safety barriers), often due to existing latent conditions, resulting in an event, which may vary from a near miss to a catastrophic occurrence. Reason’s model outlines three levels of concern: (1) the organisation/management, (2) the workplace and (3) the person (or team). Reason’s theory is still the main pillar of many contemporary methods for both risk assessment (proactive) and/or post- accident investigation (reactive). This theory was developed for complex organisations, but it also became widespread in the field of occupational safety. Socio-technical system model, by Rasmussen in 1997, and Svedung & Rasmussen in 2002. This model follows a dynamic system’s approach. It presents a multi-level 3 Celeste Jacinto – thematic lecture on accident investigation and analysis framework of a socio-technical system, ranging from the workplace (i.e., at workshop level), to management, regulators and the government. The framework is concerned with the flow of information around the various decision-makers and all parties involved. It focuses on key questions, such as how objectives and values are communicated, how operational activities are monitored through incident reporting to regulators, and how the boundaries of safe operation are identified and communicated. This model embodies the competitive dynamics and commercially aggressive environment in which many companies operate today. The model is best suited to complex Socio-technical systems (e.g., nuclear energy, offshore oil, aviation, etc.). Given the scope of this lecture, Reason’s model was discussed in more detail since this is, currently, the theory most widely used to underline many practical methods. Methods: on the other hand, as mentioned before, methods are practical tools, which help users to carry out a specific task. In the case of accidents at work, at least five methods are easily available to help safety professionals with “accident investigation and analysis”. Almost all of them supply a user’s manual. Investigating Accidents and Incidents – Users Manual. Guidance HSG245 (HSE, 2004). This is the guidance published and recommended by the British Health and Safety Executive (HSE). Available at http://www.hsebooks.com/Books/ 3CA (Control Change Cause Analysis) – Users Manual (Kingston J., 2002 and 2009). This is published by the NRI (The Noordwijk Risk Initiative), which is a non- profit European Foundation co-financed by the EU Commission, created to share good practice in risk assessment and accident investigation. Available at http://www.nri.eu.com WAIT - Work Accidents Investigation Technique – Users Manual. Verlag Dashofer (Jacinto C., 2003, 2011 4a Ed.). It was developed as part of a PhD thesis in 2003. Later on, in 2007, it was adopted by the Portuguese Senior Labour Inspectorate (SLI), for use in their official enquires. It is formally published in Portuguese, but the English version available free at http://xenofonte.demi.fct.unl.pt/wait_method 4 Celeste Jacinto – thematic lecture on accident investigation and analysis RIAAT - Recording, Investigation and Analysis of Accidents at Work – Users Manual (Jacinto et al, 2010). This is a more modern and simplified version of WAIT. It was developed under a research project entirely dedicated to accident information and learning potential. The method was also adopted by the Portuguese Senior Labour Inspectorate (SLI), for use in their official enquires. Available free (PT & EN) at Proj. CAPTAR: http://www.mar.ist.utl.pt/captar/en/home.aspx RCA - Root Cause Analysis (Análisis de Causa Raíz). AENOR (2015). This is a recommended International Standard, recently published and it offers a way of finding the root causes, which frequently are the latent causes of accidents. AENOR: Norma UNE-EN 62740:2015. Among other things, the norm suggests several accident analysis techniques and helps users on how to select a tool for “root cause” analysis. Almost all the above techniques rely on Reason’s theory for accident causation. The exception is the 3CA method that follows a generalised form of barrier analysis called "Control Change Analysis”. Of the five alternatives mentioned, the RIAAT process is explained in more detail as it offers a quite complete process to deal with accident investigation and analysis. 4. Fundamentals of the RIAAT process for analysing accidents at work The lecture continues with a summary of the RIAAT process (Recording, Investigation and Analysis of Accidents at Work). This approach offers a systematic and comprehensive structure where accidents are studied in-depth, using a "standard form" that guides the analysis and provides assistance for interviewing the injured workers. RIAAT intends to promote good practice on matters concerning accidents at work. This tool, which combines a structured methodology with a form-style protocol, is among the key outputs of a research project called CAPTAR - learn to prevent. The main objective of the project, as a whole, was to increase the efficiency of how accident information is obtained, treated, and then used to improve safety. It departs 5 Celeste Jacinto – thematic lecture on accident investigation and analysis from the assumption that the processing of accident information flows in the hierarchy through a cycle of different activities. The novelty about RIAAT is that it was designed as a “complete process” that covers the full cycle of accident information; i.e., it flows from the accident/ incident itself, to the final stage of sharing information and learning from the relevant facts, as depicted in Figure 1. INPUT Accidental events PROCESS OUTPUT Continuous Improvement Investigation & Analysis (information) Recording (data) Part II Part III Part IV Plan of Action Organisational Learning Fig. 1- Illustration of the RIAAT process Part I The “process” itself engages a cycle of activities: the recording of data in a specific format, the investigation of the pertinent facts and circumstances, the analysis of causes and their interpretation, the setting up of a plan of action, and, finally, the identification of the key people with whom to share key information to ensure organisational learning. This successive processing of information adds value to the organisation’s level of safety. All the working materials, including the user’s manual, the “form” and an application example are available at the CAPTAR web page. 5. Final remarks The lecture ends with a couple of concluding remarks, to highlight that: 1) 2) The literature is plenty of ideas, new standards, new methods, new ways, etc., to help conducting an investigation. Therefore, there are no excuses for not doing it. On the other hand, practitioners should bear in mind that methods are meant to help, not to dictate rules. They should, therefore, select the method that best suits their interests. Indeed, learning is the real “added value” and the best justification for performing the investigation and analysis of accidents at work. Sharing with others the lessons (learned from accidents) help improving safety culture and preventing accidents. 6 6. Main References (c.f. Las EEAT - Estadísticas Europeas de Accidentes de Trabajo) Celeste Jacinto – thematic lecture on accident investigation and analysis AENOR: Norma UNE-EN 62740:2015. Root Cause Analysis (Manual) (Análisis de Causa Raíz). Eurostat (2013).European Statistics on Accidents at Work (ESAW) – Methodology. Luxembourg. European Commission, DG Employment& Social Affairs, 2013 HSE – CRR (2001). Root causes analysis – literature review”. By: W.S. Atkins, Contract Research Report 325/2001 for the Health and Safety Executive, HSE Books, UK HSE - Health and Safety Executive (2004).Investigating accidents and incidents. Guidance HSG245, HSE Books, UK. ISBN: 0-7176-2827-2. (PO Box 1999, Sudbury, Suffolk CO10 2WA, UK). Available at: http://www.hsebooks.com/Books/ Jacinto, C.; Guedes Soares, C.; Fialho, T. & Silva, A.S. (2010). Users’ Manual. RIAAT - Recording, Investigation and Analysis of Accidents at Work (2010). http://www.mar.ist.utl.pt/captar/en/home.aspx Jacinto, C.; Guedes Soares, C.; Fialho, T. & Silva, A.S. (2011).The Recording, Investigation and Analysis of Accidents at Work (RIAAT) process. Policy and Practice in Health and Safety (PPHS), Vol.9(1), pp. 57-77. IOSH Publications, UK, ISSN: 1477-3996. Kjellén, Urban (2000).Prevention of accidents through experience feedback. Taylor & Francis, London. Njå, O. & Fjelltun, S.H. (2010). Managers’ attitudes towards safety measures in the commercial road transport sector. Safety Science, 48(8), pp. 1073-1080. NRI – The Noordwijk Risk Initiative Foundation (2002). 3CA – Control Change Cause Analysis Manual.By: John Kingston, NRI-3. The Netherlands. Available at: www.nri.eu.com Reason, James (1997).Managing the risks of organisational accidents. Ashgate Publishing Ltd, Aldershot Hantses_ES
dc.description.sponsorshipUniversidad de Málaga. Campus de Excelencia Internacional Andalucía Tech.es_ES
dc.language.isoenges_ES
dc.rightsinfo:eu-repo/semantics/openAccesses_ES
dc.subjectAccidentes de trabajoes_ES
dc.subject.otherSafetyes_ES
dc.subject.otherAccidentes_ES
dc.subject.otherInvestigationes_ES
dc.titleAccident Investigation and Analysis - a roadmap for organisational learning -es_ES
dc.typeinfo:eu-repo/semantics/conferenceObjectes_ES
dc.centroE.T.S.I. Industriales_ES
dc.relation.eventtitleConferenciaes_ES
dc.relation.eventplaceMálagaes_ES
dc.relation.eventdate28/11/2016es_ES
dc.rights.ccby-nc-nd


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