British Safety Council NEBOSH National Diploma in

Occupational Safety and Health

Revision Sheets
Element A2 Loss causation and incident investigation
On completion of this element, candidates should be able to demonstrate understanding of the content
through the application of knowledge to familiar and unfamiliar situations. In particular they should be
able to:
A2.l Explain theories of loss causation.
A2.2 Explain the quantitative analysis of accident / incident and ill-health data, limitations of their
application, and their presentation in numerical and graphical form.
A2.3 Explain the statutory and the internal reporting and recording systems for injuries, ill-health,
dangerous occurrences and near misses.
A2.4 Explain loss investigations, the requirements, benefits, the procedures, the documentation, and
the involvement of and communication with relevant staff and representatives.

A2.1 Theories of loss causation

Give definitions for the following
Definitions
Incident

Accident

Near-miss

Accident Ratio Triangles

A triangle is often used to numerically compare types of accidents with ascending severity outcomes.
Raw data is classified by the severity of the outcome such as major injury, minor injury and near
misses. The ratios are based on the number of low severity outcomes for 1 higher severity outcome.
E.g. For every 20 minor accidents there is 1 major accident. Studies show that outcome ratios in
organisations follow a similar pattern.
Give two reasons why outcome ratios give similar results
Outcome ratio results

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The Heinrich Theory

Use and Limitations of Accident Ratio Studies
The implications of accident ratio studies are:

All accidents and incidents should be investigated and the resources applied should be based on
the potential loss rather than the actual loss.

Near misses often have identical root causes to serious incidents and can reveal management
system failures before serious incidents occur.

Accident Causation

Single cause Domino Theory (Heinrich)

Accident involving 5 sequential factors

Each factor caused by the preceding one

Remove the factor, remove the accident

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Heinrichs Accident Domino Theory

Heinrichs five step model was modified and developed by Bird and Loftus where additional
management deficiencies are addressed.
Identify the 5 steps introduced by Bird and Loftus in their Domino Model
Bird and Loftus

Summarise the Accident Domino Theory

Accident Domino Theory

Domino Theory

Tends to be simplistic dealing with a single chain of events that may restrict the search for
multiple accident causes

Reactive rather than proactive

Not useful in predicting the likelihood of accidents

Encourages a focus on immediate rather than underlying causes.

Causes of Accidents (HSG245)

Record how the terms Root Cause and Underlying Cause are described in the document
HSG245
HSG245
Root Cause

Underlying cause

Multi-causation Theories

Several causes happening together in sequence or simultaneously

Encourages and emphasises the need for more in depth investigation to search for multiple
underlying failures

Enables the likelihood of accidents to be predicted

Encourages the use of more systematic accident analysis techniques such as fault tree and event
tree analysis
Identify 4 drawbacks to multi-causation investigations
Multi-causation investigation drawbacks

Latent failures and active conditions (Reason)

Explain what James Reason meant when he referred to Latent Failure and Active Conditions
Latent failure and Active conditions

Latent Failure

Active conditions

Levels of Failure (Reason)

1. Organisational influences
2. Unsafe supervision
3. Preconditions for unsafe acts
4. Unsafe acts themselves
(Similar to Heinrich et al)

Defences against failure are a series of barriers

Individual weaknesses in individual parts of the system

Continually varying in size and position

Failures occur when all individual barrier weaknesses align Swiss cheese model
Hazard

Some holes caused by

Active Failures

Hazards

Controlled

Some holes caused by

Latent Conditions

Hazard

Swiss Cheese Model

Barriers or Defences (Reason)

Give 3 examples each of both Hard and Soft defences
Hard and Soft defences

Hard defences

Soft defences

A2.2 Quantitative analysis of accident and ill-health data

Calculating Loss Rates
Identify the formulae for determining the following loss rates

Loss rates formulae

Accident frequency rate
Accident incidence rate
Accident severity rate
Ill-health prevalence rate

Identify 4 advantages of using accident rates as a measure of H&S performance

Advantages of using accident rates

Identify 8 disadvantages of using accident rates as a measure of H&S performance

Disadvantages of using accident rates

Epidemiological Analysis
Epidemiology
The study of the distribution and determinants of health-related states or events (including disease),
and the application of this study to the control of diseases and other health problems.
Source: World Health Organisation (WHO)
In other words it is the study of the source, spread and effect of a problem. Originally used in
conjunction with disease epidemics but is now used widely for many issues.
A common type of epidemiological analysis of accidents is by type.
Method used by HSE to determine how many falls from height, for example, occurred within a given
time frame, a specific industry or whilst carrying out certain jobs.
Also used to determine severity of injuries and the amount of time off work caused by certain types of
accidents. Car insurers use epidemiological approach in determining which types of driver, by age,
gender, location etc., are most likely to make claims and adjust premiums accordingly.
With the large amount of information available to the insurance companies the data is accurate.
Statistics
Raw data will not differentiate between:

High risk environment where risk is managed well

Low risk environment where risk is managed poorly

Patterns and trends more useful
Using accident data as a key measure is problematic due to level of reporting etc.
Identify 4 reasons why using accident data as a key indicator may be a problem
Problems with using accident data

Statistical Reliability
Reliability

How repeatable or constant are the results over time?

Variability

Have the methods of data gathering changed?

Have there been any changes to the people, environment or activities being reported on?
Validity

Consider if all of the variables are covered and the sources of data known and reliable?

Is the data collected consistent with the comparisons being made?

Has the standard deviation (error) been included in the analysis?

Identify 4 reasons why using accident data as a key indicator may be a problem
Problems with using accident data

A2.3 Reporting and recording of injuries, ill-health, dangerous occurrences

and near misses
Legal requirements to report
The Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995
Work related accidents leading to:
Fatal Injuries

Major Injuries

Minor Injuries (incapacitation)

Occupational Diseases
Dangerous Occurrences (including gas incidents
Identify 4 injuries classified as Major under RIDDOR
RIDDOR Major Injuries

Reporting Injuries to Non-Employees

Non employees injured due to work activity and taken to hospital
Quickest practicable means
Follow up in writing
Over 7 Day Injuries
Accident leading to injuries resulting in incapacitation from normal duties for more than 7 consecutive
days.
Excludes the day of the accident
Out of or in connection with work

Identify 4 events classified as Dangerous Occurrences under RIDDOR

RIDDOR Dangerous Occurrences

Identify 4 injuries classified as Reportable Diseases under RIDDOR

RIDDOR Reportable Diseases

RIDDOR Reporting Gas Incidents

Death or major injury arising from LPG container failure
Death or major injury arising from failure of flammable gas fixed pipe system
Gas leaks, faults likely to cause death / major injury
Accident book (BI510)
Accident book is required to be kept under the provision of the Social Security (Claims and Payments)
Regs 1997
Not directly related to health and safety legislation but can be utilised to record RIDDOR
Redesigned publication will allow you to comply with legal requirements to record accidents at work.
Will help organisations overcome any confusion about the requirements of both keeping personal
information in confidence and enabling information to be disclosed for preventative purposes

A2.4 Loss investigation

Legal Requirements to Investigate
Not generally explicit. Implied by:
HASWA
MHSW
RIDDOR
Responding to Accidents
Emergency response:
Take prompt emergency action (eg first aid);

Make the area safe

Initial report:
Preserve the scene;
Note the names of the people, equipment involved, witnesses; report the adverse event to the person
responsible for health and safety who will decide what further action (if any) is needed.
Initial assessment and investigation response:
Report the adverse event to the regulatory authority if appropriate.
Why Investigate?
Identify 6 reasons for investigating accidents
Reasons for investigating accidents

Identify 6 people who may be involved in accident investigations

People involved in accident investigations

Steps in Accident Investigation (HSG245)

Gathering the information
Analysing the information
Identifying risk control measures
The action plan and its implementation

HSG245 Accident Investigation Model

Gathering the Information
Record the scene and establish immediate evidence
Sketches, Plans, Photographs
Observations (physical and environmental conditions, machinery and equipment condition etc)
Documents and procedures
For serious accidents leave undisturbed until investigation complete or authorities take control
Gathering Information - Identify and Interview Witnesses
Be polite and professional
Explain what is required
Avoid leading questions
Ask open questions the Ws
Make written notes
Evidence Analysis
Identifying causes
Single and multiple causes
Immediate causes
Unsafe acts and conditions
Basic causes or Root Causes
Person, job and organisation
Lack of management control - POPIMAR
Test the evidence
Forming a Conclusion
Risk Control Measures - Remedial Actions
Based on findings and conclusions

Temporary, short term remedial actions

Taken immediately
Permanent, long term remedial actions
Taken as soon as possible
Implement control measures
Action plan what, who and by when
Review mechanism and date
Investigation procedures and methodologies
Accident/incident report forms
Gathering of relevant information
Interviewing witnesses
Analysis of information
Involvement of managers, supervisors, employees' representatives and others in the investigation
process