PROJECT: “LOSS CAUSATION MODEL” HISTORY, THEORY & APPLICATION

Fall 2014

Student: Mariana Ifteni

INTRODUCTION/ HISTORY Companies suffer a considerable loss due to accidents, and it is reflected in paying insurance cost, repair of the damage machinery, slowing down of production, additional charges on training of new specialists, and so on. Thus, a special system of accident investigation or, in other words, loss causation investigation is widely in practice. Accident investigations are conducted not only to prevent material loss, physical injury or corrective measures – the point is also to assure that the injured worker gets all material compensation necessary, or, instead, to oppose false insurance claims. Thus, inadequate safety program is reflected in the lack of workers training, necessary inspections of the equipment and so on. Inadequate safety program standards are evident when workers do not understand the peculiarity of the safety program and how to apply it, that is why insufficient compliance to standards occurs. Before a loss occurs (Injury, illness, damage, loss in process), there are series of events that take place with a root cause that begins this series of events. The root cause is called a Lack of Control (Inadequate standards, lack of compliance for preparedness, knowledge and skill training, etc). This leads to a basic cause (or personal factor) such as lack of knowledge, stress, inadequate capabilities. This in turn leads to an immediate cause (substandard conditions and actions) such as operating without authority, working under the influence of controlled substances, inadequate barriers. This then leads to an Incident – a fall, a strike, stress, or being in contact with an unfriendly environment. The incidence leads to the loss. The concept of the Loss Causation Model hence is that when a loss occurs, we need to go back that chain, realize that the root cause is not the incident or the immediate cause, and solve the problem from the root cause in order to prevent the loss from reoccurring. There are numerous accident and loss causation models in existence. The two that will be discussing in this project will be H.W. Heinrich’s Domino Theory and the ILCI Loss Causation Model. Loss causation models are used as models for safety and accident prevention theory. Loss causation models provide a direction of focus for the individual interested in reducing injuries in an organization. I. Heinrich’s principles date back to 1932 and encourage focusing on near misses instead of injury-related incidents to prevent significant losses from occurring. II. The International Loss Control Institute developed their own model in 1985, the ILCI Loss Causation model, to provide users a tool to control the vast majority of accidents and loss control problems. The ILCI model encourages focusing on development of standards, the measurement and evaluation of standards. THEORY AND APPLICATION Why do accidents happen?  This question has concerned safety and health decision makers for decades  Over the years, several theories of accident causation have evolved that attempt to explain why accidents occur  Models based on these theories are used to predict and prevent accidents

Theories of accident causation  Domino Theory of Accident Causation  Human Factors Theory of Accident Causation  Accident/Incident Theory of Accident Causation  Epidemiological Theory of Accident Causation  Systems Theory of Accident Causation  Combination Theory of Accident Causation  Behavioral Theory of Accident Causation  Drugs and Accident Causation  Depression and Accident Causation  Management Failures and Accident Causation  Obesity and Accident Causation The key points that should be made in this project are as follows:  The domino theory of accident causation was one of the earliest developed. The theory posits that injuries result from a series of factors, one of which is an accident. The theory is operational in ten statements called the Axioms of Industrial Safety. According to this theory, there are five factors in the sequence of events leading to an accident: ancestry/social environment, fault of person, unsafe act/mechanical or physical hazard, accident, and injury. Herbert W. Heinrich was an early pioneer of accident prevention and industrial safety. Henrich (1959) is credited with documenting the first scientific method of injury prevention and the effects of accidental injury causation. His reported that his studies involved 75,000 insurance accident report cases of the 1930 era. His study produced figures to indicate that  88% of the investigated accidents were caused by unsafe acts  10% due to unsafe conditions  2% as unpreventable (accidents are associated with act of God such as natural disasters. Heinrich suggests that in the majority of cases the workers individual characteristics and behaviour are the root cause the most accidents. An individual personal traits or mindsets being either inherited or acquired will predispose them to increased risk taking i.e. recklessness, stubbornness, avariciousness etc, and predisposes a concept of subjective judgment. He described the accidents causation theory, man and machine relationship, frequency and severity relation, unsafe acts reasons, management role in accident prevention, costs of accidents and the impact of safety on efficiency. According to his analysis Heinrich defined accident as an unplanned and uncontrolled event in which the action or reaction of an object, substance, person, or radiation results in personal injury or the probability of theory. Heinrich established the “Domino theory” which is based on five sequential as following:  Ancestry and social environment – are the process of acquiring knowledge of customs and skills in the workplace. Lack of skills and knowledge of performing tasks, inappropriate social and environmental conditions will lead to fault of persons.  Fault of person or carelessness – are negative features of a person personality although these

unwanted characteristics might be acquired. The result of carelessness is unsafe act/condition.  Unsafe act and/or mechanical or physical condition – include the errors and technical failures which cause the accident.  Accident– Accidents are caused by unsafe acts/conditions and subsequently lead to injuries.  Injury – Injuries are the consequences of the accidents. The Heinrich's domino theory is comprised of five standing dominos which will fall one after if the first domino (Ancestry and social environment) falls. The accident can be prevent only if the chain of sequence is disturbed, e.g., the unsafe act/condition can be eliminated in order to prevent the accidents and associated injuries. Heinrich efforts on accident causation theory can be summed up into two points, People (Human) who are the main reasons of accidents and Management which the responsibility of preventing the accidents (having the power and authority). Heinrich's domino theory was blamed for the process of simplifying the human behaviour control in accidents. Heinrich domino theory became the basis for many other studies on accident causation model with emphasis on management role in accident prevention: these studies are called Management Model or Domino's Updated Model. Management models believe that management system is responsible for occurrence of accidents. Heinrich'Axioms of Industrial safety – The reasons why people commit unsafe acts can serve as helpful guides in selecting corrective actions. The severity of an accident is largely fortuitous and the accident that caused it is largely preventable. The best accident prevention techniques are analogous with the best quality and productivity techniques.  Injuries result from a completed series of factors, one of which is the accident itself.  An accident can occur only as the result of an unsafe act by a person and /or a physical or mechanical hazard.  Most accidents are the result of unsafe behaviour by people.  An unsafe act by a person or an unsafe condition does not always immediately result in an accident/incident injury. Management should assume responsibility for safety because it is in the best position to give results. The supervisor is the key person in the prevention of industrial accidents. I addition to the direct costs of an accident , there are also hidden or indirect costs.  The human factors theory of accident causation attributes accidents to a chain of events ultimately caused by human error. It consists of three broad factors that lead to human error: overload, inappropriate response, and inappropriate activities.  Overload: Environmental factors, Internal factors, and Situational factors.  Inappropriate response: detecting a hazard but not correcting it, removing safeguards for machines and equipment, and ignoring safety.  Inappropriate activities: performing tasks without the requisite training, misjudging the degree of risk involved with a given task.

 The accident/incident theory of accident causation is an extension of the human factors theory. This theory was developed by Dan Peterson. He introduced such elements as ergonomic traps, the decision to err and the system failure. In this model, overload, ergonomic traps, and decision to err lead to human error. The system failure is an important contribution of Peterson theory. Some ways that systems fail (Peterson):  Management does not establish comprehensive safety policy.  Responsibility and authority with regard to safety are not clearly defined.  Safety procedures such as measurement, inspection, correction, and investigation are ignored or given insufficient attention.  Employees do not receive proper orientation.  Employees are not give sufficient safety training.

 The epidemiological theory of accident causation holds that the models used for studying and determining the relationships between environmental factors and disease can be used to study causal relationships between environmental factors and accidents or diseases.

 The systems theory of accident causation views any situation in which an accident might occur as a system with three components: person (host), machine (agency), and environment. The five factors to consider:  Job requirements  The workers' abilities and limitations  The gain if the task is successfully accomplished  The loss if the task is attempted but fails  The loss if the task is not attempted.  The combination theory of accident causation posits that no one model/theory can explain all accidents. Factors from two or more models might be part of the cause. There is often a degree difference between any theory of accident causation and reality. The actual cause may combine parts of several different models.

 The behaviour-based safety theory- This theory often referred to as behaviour based safety (BBS). The most prominent proponent is E. Scott Geller, a senior partner of Safety Performance Solutions, Inc. and a professor of physiology. There are seven principles:  Intervention  Identification of external factors  Motivation to behave in the desired manner  Focus on the positive consequences of appropriate behaviour  Application on the scientific method  Integration of information  Planned interventions.  Drugs and alcohol are the root or a contributing cause of many workplace accidents every year. Approximately 77 percent of drug users are employed, and more than a third of all workers between 18 and 25 are binge drinkers. Alcoholism alone causes 500 million lost days annually.  Clinical depression is an invisible problem in the workplace. However, it can be a major cause of accidents. One in 20 people suffer from clinical depression which is the root cause of more than 200 million lost workdays annually. Warning signs of clinical depressions:  Persistent dreary moots (sadness, anxiety, nervousness)  Signs of too little sleep  Sleeping on the job or persistent drowsiness  Sudden weight loss or gain  General loss of interest  Restlessness, inability to concentrate, or irritability  Chronic physical problems (headaches, digestive disorders, etc.)  Forgetfulness or inability to make simple decisions  Persistent feeling of guilt  Feelings of low self-worth  Focus on death or talk of suicide .  Management failures are another leading cause of accidents on the job. If management is serious about workplace safety and health, it must establish expectations, provide training, evaluate employee performance with safety in mind, and reinforce safe and healthy behavior. Failure to ensure a safe and healthy work environment. Supervisor play a critical role in making sure that employees work in a safe and healthy environment. Role of supervisor in workplace safety and health:  Orienting new employees to the safe way to do their jobs.  Ensuring that new and experienced employees receive the safety and health training they need on a continual basis.  Monitoring employee performance and enforcing safety rules and regulations.

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Assisting safety and health professionals in developing accident reports. Keeping up to date on safety issues. Setting a positive example for employees to say “ the safe way is the right way”

 There is a strong correlation between obesity and injuries, suggesting a need to promote optimal body weight as an injury prevention strategy. II. Loss Causation Model – ILCI Model The ILCI model was introduced in the 1970s and built on the work of Heinrich. Further research by the International Loss Control Institute (ILCI) into accident causation led them to put forward a modified domino theory. A quality-loss causation model shows different features for the loss and the causes of it. The categories for it are areas of correction, basic causes, immediate causes, incident, and loss. This model indicates that loses begin with:  Lack of control (inadequate system, standards, or compliance). With lack of control, underlying causes such as lack of training or inadequate tools and equipment are allowed to exist.  Basic causes: personal factors and job /system factors. - Personal factors such as: inadequate physical capability, inadequate mental capability, physical/mental stress, lack of knowledge, lack of skills, improper motivation, abuse or misus - Job factors such as: inadequate leadership/supervisor, inadequate engineering, inadequate purchasing, inadequate maintenance, inadequate work standards, excessive wear and tear, inadequate communication These underlying causes lead to immediate causes.  Immediate causes which are substandard conditions, or the performance of substandard act or practices. Substandard acts/practices:  using equipment improperly  operating equipment without authority  making safety devices inoperable  failure to use PPE  improper position for task  horseplay  failure to identify hazard  failure to react/correct  failure to warn  operating at improper speed  using defective equipment  improper lifting  under influence drugs/alcohol  failure to follow procedures  failure to monitor  failure to communicate/coordinate.

Immediate causes lead to the incident itself, and conclude with the loss.                Incident – event may be contact with energy or substance: struck by struck against fall abnormal operation equipment failure caught in caught between contact with: spill/release Loss may be: people: injury/illness environment: damage property: damage to equipment process: business interpretation reputation: potential negative business impact

The ILCI model emphasizes the importance of managers to evaluate the management systems that influence human behaviour rather than to blame individuals for committing substandard acts or allowing substandard conditions to exist. CONCLUSIONS Accidents and incidents in workplaces are unplanned and unwanted occurrences involving movement of persons, objects, or materials which may result in injury, damage or loss to property or people. The majority of accidents happen when employees disregard safety rules (unsafe acts) and management ignore the presence of unsafe conditions. Therefore unsafe acts and unsafe conditions are the immediate (direct) causes of accidents. On the over hand, physical and mental condition of the person as well as environmental forces and supervisory safety performance are the contributory (indirect) causes of accidents. Accidents are determined to follow a pattern: accident causation theories and models provide explanations of way. All the accidents causation theories and models developed have considerably increased the understanding of accidents and how they happen. They have stimulated a strong and powerful emphasis on the role of the human error which has resulted into a reasonable place for training and education of workers in order to develop competencies and safety awareness. However there is a fundamental dilemma which is the different interpretations of risk, safety and the extent of risk which needs to be reduced to be acceptable. People are likely to believe that once an action is executed in response to a hazard, the situation is safe or safe enough. The weakness of the loss causation theories is that they do not offer extensive strategic guidelines for managers and supervisors for reducing risks at workplaces.

Moreover, these theories have implied the inappropriate perception that accidents in workplaces can be prevented in case human errors are eliminated. Since risk is beyond the human intervention, not all accidents are preventable. Strategies require to be revised in a manner to manage the risk and workers need to be watchful of it. A great number of accidents can be prevented if the safety management system reflects both natural degradation and these intrinsic threats. The initial step in developing such system is preparing a model which shows the interaction between the accident likelihood and organizational tasks and activities in the presence of these hazards. REFERENCES/BIBLIOGRAPHY        Heinrich, H. (1959) Industrial Accident Prevention: A. Scientific Approach Mc Craw Hill 4th Edition Reason, James (2001) Managing the Risks of Organizational Accidents, England, Hants. Ashgate Publishing Limited Major theories of construction Accident Causation Model – International Journal of Advances in Engineering & Technology, Sept 2012 Learning from accidents, Accidents Causation Model – website Occupational Health and Safety for Technologists, Engineers, and Managers, David L. Goetsch 7th Edition Accident Global – http://www.es3global.com?risk-history.php Accident Investigation – http://www.ecu.edu/oehs