Module 1

Individual factors
 low skill and competence level
 tired staff
 bored or disheartened staff
 individual medical problems

Job factors
 illogical design of equipment and instruments
 constant disturbances and interruptions
 missing or unclear instructions
 poorly maintained equipment
 high workload
 noisy and unpleasant working conditions

Organisation and management factors
 poor work planning, leading to high work pressure
 poor SOPs
 lack of safety systems and barriers
 inadequate responses to previous incident
 management based on one-way communications
 deficient co-ordination and responsibilities
 poor management of health and safety
 poor health and safety culture.

It is concluded that the performance of human is being strongly influenced by organizational,
regulatory, cultural and environmental factors affecting the workplace.
For example, organizational processes constitute the breeding grounds for many predictable
human errors, including inadequate communication facilities, ambiguous procedures,
unsatisfactory scheduling, insufficient resources, and unrealistic budgeting in fact, all
processes that the organization can control.
Following figure summarizes some of the factors contributing to human errors and to
accidents

51

5 examples to show how our environment influence our behaviour?

Our behaviour is the most important thing. The way we interact with others, react to
situations and go through our daily chores eventually makes us the person we are. Be it our
work life or personal life, our surroundings shape our thoughts and our actions originate from
our thoughts. Our actions / behaviour actually shapes the way people think about us, or
whether we succeed or fail. For example, having lived in both Bangalore and Delhi, I can say
the weather does have a big effect on me. It is much easy to get angry / shout at one and all
in the sultry hot delhi weather. Even if you are not angry, it is very easy to lose your temper
on the slightest provocation. But if you are greeted by a cool breeze whenever you get out
(as in Bangalore), you tend to become happy even if you were in a bad mood earlier. The
point is, our surroundings, whether natural or chosen, tend to have an effect on our
personality and our day to day behaviour.
I am listing 5 examples how we can choose to surround ourselves with different things and
how can it bring out our best or worst –

1. Want to be creative, surround yourself with art – If you are in a job where you are required
to come up with creative ideas or just want to improve your creativity, surround yourself with
art. Keep in touch with what is happening in the art world, and look out for creative
advertisements, paintings, or any other form of art. Slowly, you will start appreciating work of
other creative people and get your mind working. You will desire to do something on the

52

same lines, and this will get you started. And continuously following up on different forms of
art can give your ideas which you can apply in your area of interest.

2. If you live near or visit places where you will find fast food restaurants or advertisements
about fast food, you will end up craving for that burger or French fries. Burger and French
Fries do taste good (though not healthy) so our mouth will start lickering and our
subconscious mind will want us to have it. And if you are hungry at that time, the craving
might get to you and you might end up eating fast food instead of doing what you should be.
I am thinking of going to a MacDonald today as I am writing this piece, and I need to move on
to the next point before I head to grab my fries. (Unfortunately, a MacD joint is just across
the street where I live)

3. Expose yourself to metrics about your work or business or performance and you’ll work to
improve them. Metrics, and depicting them by graphs and other forms of pictorial
representation give us a sense of how we are doing and how we should be doing. If we keep
track of such metrics, we will work on improving them. It is the same reason schools and
colleges have marks or grades so that people know what to measure and how to improve on
those metrics. Collecting metrics is a qualitative way of improving stuff that is otherwise
difficult to measure, and hence easy to ignore. If you want to improve something, find a way
to measure it and surround yourself with info about it and you will see yourself working to
improve it.

4. If you see a lot of negative emotions in your daily life, you will tend to react to situations
with a negative bend of mind. If you see people getting angry at each other, you might end
up justifying their actions and find reasons to get angry yourself. If you fear something, then
thinking about it or being in a vicinity which reminds you of your fear, you will tend up acting
more reluctantly on matters you would have been confident otherwise. So, if you tend to be
around people experiencing negative emotions like frustration, worry, anger,
disappointment, be aware that they can spread to you very easily.

5. If you interact with people making smart decisions, you will also take interest in it and
learn from them. You will slowly and surely be able to understand how to handle different

53

situations and how to go about in your decision-making process. Your thought process will
start reflecting the people who you spend time with. You will understand why they took a
certain decision and will try to learn from it.
Eventually, it is a choice of how we choose our surroundings. If you want a change in
yourself, then just spend time with people / situations where you see that change. This holds
true for both negative and positive thoughts.

54

Describe the factors that influence the behavior of people and give
examples of this in a work environment

Factors Influencing Individual Behavior
The way an individual address a situation single-handedly or say in a group is influenced by
many factors. The key factors influencing an individual’s attitude in personal as well as social
life are −

 Abilities
 Gender
 Race and culture
 Attribution
 Perception
 Attitude
Abilities
Abilities are the traits a person learns from the environment around as well as the traits a
person is gifted with by birth. These traits are broadly classified as −
 Intellectual abilities
 Physical abilities
 Self-awareness abilities

In order to understand how these, affect a person’s behavior, we need to know what these
abilities are.

 Intellectual abilities − It personifies a person’s intelligence, verbal and analytical
reasoning abilities, memory as well as verbal comprehension.

 Physical abilities − It personifies a person’s physical strength, stamina, body
coordination as well as motor skills.

 Self-awareness abilities − It symbolizes how a person feels about the task, while a
manager’s perception of his abilities decides the kind of work that needs to be
allotted to an individual.

55

Thus, the psychological, physical, self-assurance traits owned by a person defines the
behavior of a person in social and personal life. For ex: Ram has a high IQ level, whereas
Rahul can lift a bike and is a strong guy.

Gender

Research proves that men and women both stand equal in terms of job performance and
mental abilities; however, society still emphasizes differences between the two genders.
Absenteeism is one area in an organization where differences are found as women are
considered to be the primary caregiver for children. A factor that might influence work
allocation and evaluation in an organization is the manager’s perception and personal values.

Race & Culture
Race & culture have always exerted an important influence both at the workplace as well as
in the society. The common mistakes such as attributing behavior and stereotyping according
to individual’s race & culture basically influences an individual’s behavior.

Perception
Perception is an intellectual process of transforming sensory stimuli into meaningful
information. It can be divided into six types namely −

 Of sound − the ability to receive sound by identifying vibrations.
 Of speech − the competence of interpreting and understanding the sounds of

language heard.
 Touch − Identifying objects through patterns of its surface by touching it.
 Taste − the ability to detect flavor of substances by tasting it through sensory organs

known as taste buds.
 Other senses − other senses include balance, acceleration, pain, time, sensation felt in

throat and lungs etc.
 Of the social world − It permits people to understand other individuals and groups of

their social world.
Attribution

56

Attribution is the course of observing behavior followed by determining its cause based on
individual’s personality or situation.
Attribution framework uses the following three criteria −

 Consensus − the extent to which people in the same situation might react similarly.
 Distinctiveness − the extent to which a person’s behavior can be associated to

situations or personality.
 Consistency − the frequency measurement of the observed behavior, that is, how

often does this behavior occur.
The framework mentioned says it is all about how an individual behaves in different
situations.

Attitude
Attitude is the abstract learnt reaction or say response of a person’s entire cognitive process
over a time span.
For example − A person who has worked with different companies might develop an attitude
of indifference towards organizational citizenship.

Topic Quiz
1. Intellectual abilities
2. Physical abilities
3. Self-awareness abilities

57

Identify and explain the role of behavioral modification in
influencing the overall health and safety of employees

Behavior modification

Based on methodological behaviorism, overt behavior was modified through the use of
presumed consequences, including positive and negative reinforcement contingencies to
increase desirable behavior, or administering positive and
negative punishment and/or extinction to reduce behavior.

Only human
The human factors theory that underpins behavior-modification systems is a mix of three
academic disciplines: occupational psychology, sociology and anthropology
The mental ones are as follows.

 Attitude: behavioral tendencies.
 Motivation: the factors which help direct or drive the way an individual or group acts.
 Perception: the individual or group's view of their (working) environment and what

happens there.
 Mental capability: the ability to understand and use information in the correct (and

safe) manner.

Rule of four

The HSE research listed four main categories of critical OSH behaviors:
 leadership and direction
 management actions
 risk-control behaviors
 Front-line OSH behaviors.

58

Leadership and direction behavior hinges on the demonstration of visible commitment to
OSH management ("management by walking about" again) and the prioritization of OSH
management in mission statements, promoting good corporate governance/corporate social
responsibility.

Management actions include investing in new, safer plant and equipment, improving training
and communication programs and recruiting suitable and sufficiently competent people.

Risk-control behaviors involve undertaking and communicating risk assessments, together
with appropriate workplace precautions. They also involve compliance with agreed operating
or emergency procedures.
These three categories account for the majority of OSH behaviors.

Well behaved

Behavior-modification programs have three main elements.
The first involves pinpointing relevant behaviors, specifying carefully the ones that need
changing and directly measuring behavior.
The second is analyzing the behavior and focusing on the antecedents (influencing factors)
and consequences. Perception of possible consequences has a powerful impact on
determining our behavior; antecedents, such as OSH policy, management training, individual
targets, can also have a very important impact.
The third element is an emphasis on evaluation - checking rigorously whether behavior has
changed as intended and whether the change was due to the planned intervention or to
other factors.

Interventions aimed at changing behavior (especially at directorial or managerial levels) will
vary depending on the organizational setting, the target population and behaviors that need
altering. The HSE report suggests that the three main elements outlined above lend
themselves to a six-step intervention process.

1. Establishing the desired result or output of the activity or the individuals under
examination.

59

2. Specifying those critical behaviors that influence performance in the area(s) to be
improved.

3. Ensuring the individuals are capable of behaving in the desired way.
4. Conducting an ABC analysis (antecedents, behaviors, consequences) of the current

and desired behaviors, changing antecedents where necessary.
5. Altering the consequences immediately following the desired behaviors.
6. Evaluating the impact of altering the consequences on the behavior and on the

desired result.
This process can be used to promote and analyses any critical health and safety behavior at
director/manager level. The effectiveness of any OSH management system relies almost
entirely on the behaviors of all employees plus any contractors and visitors.

The purpose of any RCS is to make sure that appropriate workplace precautions are in place.
Behavior-modification interventions help this process by increasing the frequency of critical
behaviors needed to minimize risk, and by reducing those that increase risk.

Critical point

Critical behaviors include those required to control risk (such as permit systems), risky
activities (such as manual handling), and actions that support the OSH management system
(displaying visible management commitment, for instance).

The outputs from the behavior-modification process - the interventions that will help
promote safe behavior - may be used as part of the audit process, for example to indicate the
general level of compliance by managers and supervisors with the agreed systems and
procedures associated with the list of critical behaviors.

Identifying the activities that involve critical behaviors involves looking closely at all the
elements of the OSH management system, from the policy to the review procedure.
Consulting directors, managers, supervisors and external personnel, such as insurance
assessors, and reviewing accident investigation reports for immediate and root behavioral
causes of incidents will also provide valuable leads.

60

Explain what contribution leadership can make towards creating a
culture where unacceptable behavior regarding health and safety issues
are not tolerated
Leadership influence on health and safety behavior of employees by implementing an OSH
culture
A health and safety culture are regarded as the key factor when it comes to determining the
effectiveness of a safety system, Culture is rather based on behavior, every day actions and
decision and goes far beyond health and safety policies, even though it is of major
importance to integrate core values based on a policy into the whole process
of implementing and maintaining good health and safety behavior.

Topic Quiz
1. What is behavior
2. What is behavior modification

3. Give factors that influence individual behavior

61

FORMATIVE ASSESEMENT - FOUR
 IAC0401 Given at least three different safety behaviour scenarios be able to; a. Identify the

correct safety behaviours; b. Identify incorrect safety behaviours; c. Describe what must be done
to improve the safety behaviours.

62

1.2.5. KM-01-KT05: Concepts and principles of emergency
preparedness and response (Basic)

KT0501 Explain the definition of an emergency and give examples of typical emergencies that
KT0502 could occur in the workplace;
KT0503 Explain the difference between preparedness and response and give examples of typical
KT0504 preparedness and response actions;
Describe the roles of the various role players to ensure that an organization is adequately
prepared for emergencies;
Describe the roles of the various role players when an emergency occurs.

 Emergency Response Plan also acts as a way to address advance proportions and
preventive measure for emergency situations. It must also identify those who are
responsible for taking immediate action after the discovery of, and during the response to
an emergency, as well as their respective duties.

 An emergency is a situation that poses an immediate risk to health, life, property,

or environment.

63

Explain the definition of an emergency and give examples of
typical emergencies that could occur in the workplace;

Emergency
An emergency is a situation that poses an immediate risk to health, life, property,
or environment. Most emergencies require urgent intervention to prevent a worsening of the
situation, although in some situations, mitigation may not be possible and agencies may only
be able to offer palliative care for the aftermath.

Defining an emergency
An incident, to be an emergency, conforms to one or more of the following: if it:

 Poses an immediate threat to life, health, property, or environment
 Has already caused loss of life, health detriments, property damage, or environmental

damage
 Has a high probability of escalating to cause immediate danger to life, health,

property, or environment?

Agencies involved in dealing with emergencies

Most developed countries have a number of emergency services operating within them,
whose purpose is to provide assistance in dealing with any emergency. They are often
government operated, paid for from tax revenue as a public service, but in some cases, they
may be private companies, responding to emergencies in return for payment, or they may be
voluntary organisations, providing the assistance from funds raised from donations.
Most developed countries operate three core emergency services:

 Police – who deal with security of person and property, which can cover all three
categories of emergency. They also, to some extent, deal with punishment of those
who cause an emergency through their actions.

64

 Fire service – who deal with potentially harmful fires, but also often rescue operations
such as dealing with road traffic collisions. Their actions help to prevent loss of life,
damage to health and damage to or loss of property.

 Emergency Medical Service (Ambulance / Paramedic service) – These services
attempt to reduce loss of life or damage to health. This service is likely to be decisive
in attempts to prevent loss of life and damage to health. In some areas "Emergency
Medical Service" is abbreviated to simply EMS.

In some countries or regions, two or more of these services may be provided by the same
agency (e.g. the fire service providing emergency medical cover), and under different
conditions (e.g. publicly funded fire service and police, but a private ambulance service)
There may also be a number of secondary emergency services, which may be a part of one of
the core agencies, or may be separate entities who assist the main agencies. This can include
services providing specialist rescue (such as mountain rescue[14] or mine rescue),[15] bomb
disposal[16] or search and rescue.
The Military and the Amateur Radio Emergency Service (ARES) or Radio Amateur Civil
Emergency Service (RACES) help in large emergencies such as a disaster or major civil unrest.

Summoning emergency services

Main article: Emergency telephone number
Most countries have an emergency telephone number, also known as the universal
emergency number, which can be used to summon the emergency services to any incident.
This number varies from country to country (and in some cases by region within a country),
but in most cases, they are in a short number format, such as 911

The majority of mobile phones also dial the emergency services, even if the phone keyboard
is locked, or if the phone has an expired or missing SIM card, although the provision of this
service varies by country and network

65

Key emergency principle
The key principle taught in almost all systems is that the rescuer, be they a lay person or
a professional, should assess the situation for danger.[29][30]
The reason that an assessment for danger is given such high priority is that it is core to
emergency management that rescuers do not become secondary victims of any incident, as
this creates a further emergency that must be dealt with.
A typical assessment for danger would involve observation of the surroundings, starting with
the cause of the accident (e.g. a falling object) and expanding outwards to include any
situational hazards (e.g. fast moving traffic) and history or secondary information given
by witnesses, bystanders or the emergency services (e.g. an attacker still waiting nearby).
Once a primary danger assessment has been complete, this should not end the system of
checking for danger, but should inform all other parts of the process.
If at any time the risk from any hazard poses a significant danger (as a factor of likelihood and
seriousness) to the rescuer, they should consider whether they should approach the scene
(or leave the scene if appropriate).

Managing an emergency

66

A graphic representation of the four phases in emergency management.

There are many emergency services protocols that apply in an emergency, which usually start
with planning before an emergency occurs. One commonly used system for demonstrating
the phases is shown here on the right.
The planning phase starts at preparedness, where the agencies decide how to respond to a
given incident or set of circumstances. This should ideally include lines of command and
control, and division of activities between agencies. This avoids potentially negative situations
such as three separate agencies all starting an official centre for victims of a disaster.
Following an emergency occurring, the agencies then move to a response phase, where they
execute their plans, and may end up improvising some areas of their response (due to gaps in
the planning phase, which are inevitable due to the individual nature of most incidents).
Agencies may then be involved in recovery following the incident, where they assist in the
clear up from the incident, or help the people involved overcome their mental trauma.
The final phase in the circle is mitigation, which involves taking steps to ensure no re-
occurrence is possible, or putting additional plans in place to ensure less damage is done.
This should feed back into the preparedness stage, with updated plans in place to deal with
future emergencies, thus completing the circle.

What's the difference between emergency preparedness and emergency response?

Emergency preparedness refers to actions which can and should be performed prior to an
emergency, such as planning and coordination meetings, procedure writing, team training,
emergency drills and exercises, and prepositioning of emergency equipment. Emergency
response refers to actions taken in response to an actual, ongoing event.

Identification of potential emergency situations
Procedures to identify potential emergency situations that could impact on SHE should
consider emergencies that can be associated with specific activities, equipment or
workplaces.

Examples of possible emergencies, which vary in scale, can include:

67

 Incidents leading to serious injuries or ill health,
 fires and explosions,
 fall of ground
 release of hazardous materials/gases,
 explosives and explosions
 natural disasters, bad weather,
 loss of utility supply (e.g. loss of electric power),
 pandemics/epidemics/outbreaks of communicable disease,
 civil disturbance, terrorism, sabotage, workplace violence,
 failure of critical equipment,
 theft critical equipment
 criminal activity
 Traffic interaction and accidents.

When identifying potential emergency situations, consideration should be given to
emergencies that can occur during both normal operations and abnormal conditions (e.g.
operation start-up or shutdown, construction or demolition activities).

Emergency planning should also be reviewed as a part of the ongoing management of
change. Changes in operations can introduce new potential emergencies or necessitate that
changes be made to emergency response procedures. For example, changes in facility layout
can impact emergency evacuation routes.

The company should also consider potential impacts on emergency services personnel while
at the workplace (e.g. fire-fighters). Information that should be considered in identifying
potential emergency situations includes the following:
 the results of hazard identification and risk assessment
 activities performed during the SHE planning process
 legal requirements, the company’s previous incident (including accident) and emergency

experience,
 emergency situations that have occurred in similar companies,
 information related to accident and/or incident investigations

68

 Posted on the websites of regulators or emergency response agencies.

Establishing and implementing emergency response procedures
Emergency response should focus on the prevention of ill health and injury, and on the
minimization of the adverse Health and Safety consequences to a person(s) exposed to an
emergency situation.

A procedure(s) for responding to emergency situations should be developed and should also
take into account applicable legal and other requirements.

The emergency procedure(s) should be clear and concise to facilitate their use in emergency
situations. They should also be readily available for use by emergency services. Emergency
procedure(s) that are stored on a computer or by other electronic means might not be
readily available in the event of a power failure, so paper copies of emergencies procedure(s)
ought to be maintained in readily accessible locations.

Consideration should be given to the existence and/or capability of the following, in
developing emergency response procedure(s):
 inventory and location of hazardous materials storage, numbers and locations of people,
 critical systems that can impact on SHE, the provision of emergency training,
 detection and emergency control measures, medical equipment, first aid kits, etc.,
 control systems, and any supporting secondary or parallel/ multiple control systems,
 monitoring systems for hazardous materials,
 fire detection and suppression systems,
 emergency power sources, e.g. Cable theft is a serious concern in South Africa
 availability of local emergency services and details of any emergency response

arrangements currently in place,
 legal and other requirements,
 Previous emergency response experience.

Emergency response procedure(s) should define the roles, responsibilities and authorities of
those with emergency response duties, especially those with an assigned duty to provide an

69

immediate response. These personnel should be involved in the development of the
emergency procedure(s) to ensure they are fully aware of the type and scope of emergencies
that they can be expected to handle, as well as the arrangements needed for coordination.
Emergency service personnel should be provided with the information required to facilitate
their involvement in response activities.

Emergency response procedures should give consideration to the following:
 identification of potential emergency situations and locations,
 details of the actions to be taken by personnel during the emergency (including actions to

be taken by staff working off-site, by contractors and visitors),
 evacuation procedures, responsibilities, and authorities of personnel with specific

response
 duties and roles during the emergency (e.g. fire wardens, first-aid staff and spill clean-up

specialists),
 interface and communication with emergency services,
 communication with employees (both on-site and off-site),
 regulators and other interested parties (e.g. family, neighbors, local community, media),
 information necessary for undertaking the emergency response
 (Plant and mine layout drawings, identification and location of emergency response

equipment, identification and location of hazardous materials, utility shut-off locations,
contact information for emergency response providers).
Emergency response equipment

The company should determine and review its emergency response equipment and material
needs. Emergency response equipment and materials can be needed to perform a variety of
functions during an emergency, such as evacuation, leak detection, fire suppression,
chemical/biological/radiological monitoring, communication, isolation, containment, shelter,
personal protection, decontamination, and medical evaluation and treatment. Emergency
response equipment should be available in sufficient quantity and stored in locations where it
is readily accessible; it should be stored securely and be protected from being damaged. This
equipment should be inspected and/or tested at regular intervals to ensure that it will be
operational in an emergency situation. Special attention should be paid to equipment and

70

materials used to protect emergency response personnel. Individuals should be informed of
the limitations of personal protective devices and trained in their proper use.

Topic Quiz

1. Identification of potential emergency situations

71

Describe the roles of the various role players to ensure that an
organization is adequately prepared for emergencies;

Emergency management is the organization and management of resources and
responsibilities for dealing with all humanitarian aspects of emergencies (preparedness,
response, and recovery). The aim is to reduce the harmful effects of all hazards,
including disasters. It should not be equated to "disaster management".
The World Health Organization defines an emergency as the state in which normal
procedures are interrupted, and immediate measures need to be taken to prevent that state
turning into a disaster.

Establishing the planning team
The emergency planning team, comprising of a diverse group of people from various
departments, is responsible for the development and administration of the emergency
preparedness plan. Typically, the safety manager takes overall responsibility for developing
the plan.
Analyzing capabilities and hazards

Personnel, equipment, facilities, and organizational resources that play a role during a mine
emergency need to be evaluated in terms of being able to provide the desired effect. For
example, if this team is composed of miners who have never been involved in an emergency

72

operation, they may have limited capabilities during a mine emergency. Furthermore, the
causes and their potential consequences of an emergency should be identified in advance.
Such a risk assessment allows the mine operation to take appropriate countermeasures in
order to minimize the prospect of the event causing an emergency. Risk management helps
move the mine from a culture of reaction to a culture of prevention.

Develop the plan
After all variables have been assessed The MERP is developed. It would include the mine
operation’s emergency management policy; authorities and responsibilities of key personnel;
the types of emergencies that could occur; how and where these emergencies will be
managed; and how recovery efforts will be structured.

Implementing the plan
Implementing the plan means acting on the recommendations that were made during the
risk assessment; integrating the plan into mining operations; training employees;
and evaluating and revising the plan. The MERP should be woven intricately into the mining
operation’s culture; otherwise, it remains pinned down amongst dozens of files of good
intentions, that have never been executed and never saved lives.

Topic Quiz
1. How to prepare a good Emergency Response Plan?
2. What is an emergency response plan?

73

FORMATIVE ASSESEMENT - FIVE
 IAC0501 Given different business scenarios and descriptions of various emergencies be able to; a.

Indicate what emergency plans must be in place in the typical businesses; b. Identify what was
done correctly when dealing with the different emergencies; c. Describe the responsibilities of the
various role players in the given emergencies.

74

1.2.6. KM-01-KT06: The principles of hazards identification
and risks assessment(Basic)

KT0601 Give practical examples to explain what a hazard is and how hazards relate to risks
KT0602 Explain the concept of priority setting and relate it to the process of hazard and risk
rating

What a hazard is and how hazards relate to risks?

A hazard is an agent which has the potential to cause harm to a vulnerable target. The terms
"hazard" and "risk" are often used interchangeably. However, in terms of risk assessment,
these are two very distinct terms. A hazard is any agent that can cause harm or damage to
humans, property, or the environment. Risk is defined as the probability that exposure to a
hazard will lead to a negative consequence, or more simply, a hazard poses no risk if there is
no exposure to that hazard.
Hazards can be dormant or potential, with only a theoretical probability of harm. An event
that is caused by interaction with a hazard is called an incident. The likely severity of the
undesirable consequences of an incident associated with a hazard, combined with
the probability of this occurring, constitute the associated risk. If there is no possibility of a
hazard contributing towards an incident, there is no risk.

Hazards can be classified as different types in several ways. One of these ways is by specifying
the origin of the hazard. One key concept in identifying a hazard is the presence of stored
energy that, when released, can cause damage. Stored energy can occur in many forms:
chemical, mechanical, thermal, radioactive, electrical, etc. Another class of hazard does not
involve release of stored energy, rather it involves the presence of hazardous situations.
Examples include confined or limited egress spaces, oxygen-depleted atmospheres, awkward
positions, repetitive motions, low-hanging or protruding objects, etc. Hazards may also be
classified as natural, anthropogenic, or technological. They may also be classified as health or
safety hazards, by the populations that may be affected, and the severity of the associated

75

risk. In most cases a hazard may affect a range of targets, and have little or no effect on
others.
Status of a hazard

Hazards are sometimes classified into three modes or statuses:
 Dormant—The situation environment is currently affected. For instance, a hillside
may be unstable, with the potential for a landslide, but there is nothing below or on
the hillside that could be affected.
 Armed—People, property, or environment are in potential harm's way.
 Active—A harmful incident involving the hazard has actually occurred. Often this is
referred to not as an "active hazard" but as an accident, emergency, incident,
or disaster.

Risk

The terms "hazard" and "risk" are often used interchangeably. However, in terms of risk
assessment, these are two very distinct terms. A hazard is an agent that can cause harm or
damage to humans, property, or the environment. Risk is the probability that exposure to a
hazard will lead to a negative consequence, or more simply, a hazard poses no risk if there is
no exposure to that hazard.
Risk can be defined as the likelihood or probability of a given hazard of a given level causing a
particular level of loss of damage. The elements of risk are populations, communities,
the built environment, the natural environment, economic activities and services which are
under threat of disaster in a given area. The total risk according to UNDRO 1982 is the "sum
of predictable deaths, injuries, destruction, damage, disruption, and costs of repair and
mitigation caused by a disaster of a particular level in a given area or areas.

76

Marking of hazards

Skull and crossbones, a common symbol for poison and other sources of lethal danger (GHS
hazard pictograms).

Hazard symbols or warning symbols are easily recognizable symbols designed to warn about
hazardous materials, locations, or objects, The use of hazard symbols is often regulated by
law and directed by standards organizations. Hazard symbols may appear with different
colors, backgrounds, borders and supplemental information in order to specify the type of
hazard and the level of threat (for example, toxicity classes). Warning symbols are used in
many places in lieu of or addition to written warnings as they are quickly recognized (faster
than reading a written warning) and more universally understood, as the same symbol can be
recognized as having the same meaning to speakers of different languages.

Identification of hazards assumes that the potential targets are defined, and is the first step
in performing a risk assessment.

Risk assessment is the determination of quantitative or qualitative estimate of risk related to
a well-defined situation and a recognized threat (also called hazard). Quantitative risk
assessment requires calculations of two components of risk (R): the magnitude of the
potential loss (L), and the probability (p) that the loss will occur. An acceptable risk is a risk
that is understood and tolerated usually because the cost or difficulty of implementing an
effective countermeasure for the associated vulnerability exceeds the expectation of loss.
"Health risk assessment" includes variations, such as the type and severity of response, with
or without a probabilistic context.

77

Assessment of risk

At the strategic level policies are made specifying acceptable levels of risk, procedures to be
followed within the organisation, priorities and allocation of resources.: At the systematic
level, management involved with the project produce project level risk assessments with the
assistance of the available expertise as part of the planning process, and set up systems to
ensure that required actions to manage the assessed risk are in place. At the dynamic level,
the personnel directly involved may be required to deal with unforeseen problems in real
time. The tactical decisions made at this level should be reviewed after the operation to
provide feedback on the effectiveness of both the planned procedures and decisions made in
response to the contingency.
The first step in risk assessment is to establish the context This restricts the range of hazards
to be considered.
This is followed by identification of visible and implied hazards that may threaten the project,
and determining the qualitative nature of the potential adverse consequences of each hazard.
Without a potential adverse consequence, there is no hazard.
It is also necessary to identify the potential parties or assets which may be affected by the
threat, and the potential consequences to them if the hazard is activated.

If the consequences are dependent on dose, i.e. the amount of exposure, the relationship
between dose and severity of consequence must be established, and the risk depends on the
probable dose, which may depend on concentration or amplitude and duration or frequency
of exposure. This is the general case for many health hazards where the mechanism of injury
is toxicity or repetitive injury, particularly where the effect is cumulative.
For other hazards, the consequences may either occur or not, and the severity may be
extremely variable even when the triggering conditions are the same. This is typical of many
biological hazards as well as a large range of safety hazards. Exposure to a pathogen may or
may not result in actual infection, and the consequences of infection may also be variable.
Similarly, a fall from the same place may result in minor injury or death, depending on

78

unpredictable details. In these cases, estimates must be made of reasonably likely
consequences and associated probability of occurrence.
In cases where statistical records are available they may be used to evaluate risk, but in many
cases, there are no data or insufficient data available to be useful. Mathematical or
experimental models may provide useful input

Dynamic risk assessment

During emergency response the situation and hazards are often inherently less predictable
than for planned activities. In general, if the situation and hazards are predictable, standard
operating procedures should deal with them adequately, and in some emergencies, this
holds true and the prepared and trained responses are adequate to manage the situation.
These situations are usually those that the operator can deal with without outside assistance,
or with the assistance of a backup team who are prepared and available to step in at short
notice. Other emergencies occur where there is no previously planned protocol, or when an
outsider group is brought in to handle the situation, and they are not specifically prepared for
the scenario that exists, but must deal with it without undue delay. Examples include police,
fire department, disaster response and other public service rescue teams. In these cases,
ongoing risk assessment by the involved personnel can advise appropriate action to reduce
risk. HM Fire Services Inspectorate has defined dynamic risk assessment (DRA) as:
The continuous assessment of risk in the rapidly changing circumstances of an operational
incident, in order to implement the control measures necessary to ensure an acceptable level
of safety.
Dynamic risk assessment is the final stage of an integrated safety management system which
can provide appropriate response during changing circumstances. It relies on experience,
training and continuing education, including effective debriefing to analyse not only what
went wrong, but also what went right, and why, and to share this with other members of the
team and the personnel responsible for the planning level risk assessment.

79

FORMATIVE ASSESEMENT - SIX
 IAC0601 Given scenarios of typical workplace situations learners will indicate all the hazards in the

given scenario and describe the risks that these hazards bring about

80

1.2.7. KM-01-KT07: Principles of safe working practices in
and around the place of work (Intermediate)

KT0701 Explain what is meant by a working practice using practical examples (NQF
KT0702 Level: 2)
Explain the concept of habits and how good and bad habits can be established
with specific reference to occupational health and safety situations (NQF Level:
2)

 Safe work practices are generally written methods outlining how to perform a task with
minimum risk to people, equipment, materials, environment, and processes

 Environmental Management a robust environmental database application contains the
various local and national regulations with which a mine operator must comply

81

Principles of safe working practices in and around the place of
work (Intermediate)

What does Safe Work Practices (SWP) mean?
Safe work practices are generally written methods outlining how to perform a task with
minimum risk to people, equipment, materials, environment, and processes. These are
guidelines like do’s and don’ts but may not always be suitable when a new hazard been
identified. Employees should know, understand and follow the SWPs those are applicable to
own work.

Development
Safe work practices should be developed as a result of completing a Hazard Assessment and
should closely reflect the activities most common in the company's type or sector of
construction. As the new workers are more prone to accidents at workplaces, they need to
be trained more on SWP. An example of SWP is placing a notice 'mind your steps’ at the
beginning of a staircase.

The following features are helpful in implementing safe work practices at workplace:
 Induction training for new employees.
 Training on communication and teamwork during normal and emergency situation.
 Training on fire safety and emergency procedures.
 Training on hazard identification, risk control, use of personal protection equipment
(PPE) and first aid.
 Observation of ergonomics to reduce injuries to workers.
 Use and maintenance of appropriate tools for work and keeping them in good
working condition.
 Handling, application, labelling and storage of hazardous and non-hazardous
materials so the workers are not exposed to danger.
 Adherence to policies and procedures to set standard actions and reactions
understandable by all and to reduce chaos in an emergency.

82

 Housekeeping, cleaning and waste disposal considering environment safety and
health (ESH).

Delivery

All safe work practices should be kept in a location central to the work being performed and
readily available to the workforce. Some safe work practices will require specific job
procedures, which clearly set out in a chronological order each step in a process.

A best practice is a method or technique that has been generally accepted as superior to any alternatives
because it produces results that are superior to those achieved by other means or because it has become a
standard way of doing things, e.g., a standard way of complying with legal or ethical requirements.

Safe Work Habits

"Habit is the deepest law of human nature" Most of us would probably agree with that.
People are quite often influenced by habit. Habit and job safety is also closely related. If you
form safe work habits, it's going to reflect positively in everyone’s job safety. There are seven
(7) common "human factors" related to developing safe work habits. Let's review them.

Hazard Recognition --- Recognition of hazards is an important factor. By constantly being on
the lookout for hazards you enhance your own safety. In watching for hazards, you must
consider not just the obvious ones, but also hazards which might suddenly appear through
some action of another person or a chain of unusual circumstances. Whenever a hazard is
detected, report it to someone who can make the change.

Avoiding Indifference --- Avoiding indifference on the job is important to safety. An individual
might know the right way to do his or her particular job, and just ignore it. Sometimes the
most experienced person who has had the safety related training might tend to avoid doing
the job the right way. Or there may be the employee who does not know the safety
procedures and instead of finding them out chooses to also ignore them. These kinds of
indifferences on the job can and do lead to trouble and accidents.

83

Eliminating "Daredevil" Behaviour --- Ok admit it, have you ever done or known anyone who
has done a daredevil stunt or taken a quick chance? How about standing on the top rung of a
ladder? Everyone knows you should not do that, sometimes the ladder is even posted "do
not stand above a certain level" but we do it anyway. Eliminating "daredevil" behaviour is
another human factor that can prevent injury on the job and at home.

Setting a Good Example --- Setting a good example is another factor to consider. We have all
heard this statement before. "If you set a good example then others will follow". Think about
how your actions at work and at home may affect the attitudes of others. The actions of all of
us have an influence on the safety-mindedness of others. Think of it this way, when you are
in your car traveling to one place or another do you leave room between cars or do you have
a tendency to tailgate? Think how the other person may feel, stressed, I bet. If a veteran
employee follows the safety rules then the newer employee may follow their lead but on the
other hand if we condone the unsafe acts of others then that behaviour may be what we now
call the culture of the company.

Avoiding Impulsiveness --- Another link in the chain of job safety is avoiding impulsiveness or
being in a hurry. Haste is a trait that often leads to accidents. We are using our time foolishly
if we don't take the time to be safe. Many valuable timesaving suggestions are contributed by
employees each year, but, these timesaving suggestions should be reviewed and approved
before they are used. Haste can result in injury!

Controlling Impatience --- Controlling impatience and temper is equally important to job
safety. If we let emotions get out of control, an accident can easily occur. Statistics prove that
on the job violence is on the increase in our country. Do you have programs in place that
identifies potential problems before tempers get out of control? And, what kind of programs
do you have established to get help for your employees.

Proper Training and Instruction --- Finally, one of the most important human factors related
to safe work habits is training. From the day we are born we are being trained. Some of this

84

training or learning may have been good, and we probably picked up some bad habits along
the way. Job training and safety go hand in hand. While the supervisor is responsible for
training, each employee must be responsible to ask questions if instructions are not clear or if
there are any doubts about procedures. Unfortunately, some experienced employees may be
so familiar with their jobs that they become inattentive, and this too is hazardous.
Proper work habits can assure job safety. Overall, the responsibilities for developing safe
work habits really belong to each of us. By being aware of the "human factors" we've just
reviewed, safe work habits can be formed and job safety assured. This can and does affect
your bottom line.

85

FORMATIVE ASSESEMENT - SEVEN
 IAC0701 Using experiences from personal work life learners describe typical safe and

unsafe work practices (Weight: 5%)

86

1.2.8. KM-01-KT08: Techniques of accident and incident
investigation

KT0801 Explain the difference between an accident and incident (NQF Level: 2)
KT0802 Describe the generally accepted hierarchy of how incidents lead to accidents (NQF
Level: 2)
KT0803 Explain the basic process of accident and incident investigation (NQF Level: 2)

 Accident investigation techniques
 Six steps for successful incident investigation

 Accident & Incident Investigation

Accident

An accident, also known as an unintentional injury, is an undesirable, incidental, and unplanned event that could
have been prevented had circumstances leading up to the accident been recognized, and acted upon, prior to

87

its occurrence. Most scientists who study unintentional injury avoid using the term "accident" and focus on
factors that increase risk of severe injury and that reduce injury incidence and severity (Robertson, 2015)

Techniques of accident and incident investigation

Accident investigation techniques
All accidents are incidents, but not all incidents are accidents. That's a very brief answer to
the common query about the difference between the two terms

Applying this definition makes it obvious the category "incidents" is larger than the category
"accidents". If all accidents are unplanned, unexpected events (see later for a full accident
definition), some incidents that result in damage or injury are highly planned events, such
as terrorist attacks or bank robberies.

What is an accident?
"Some concrete happening which intervenes or obtrudes itself upon the normal cause of
employment. It has the ordinary everyday meaning of an unlooked-for mishap or an
untoward event which is not expected or designed by the victim."

Taking the best of the definitions, one that covers all the bases might run as follows: "An
accident is an unexpected, unplanned event, in a sequence of events that occurs through a
combination of causes; it results in physical harm - injury or disease - to an individual,
damage to property, a near miss, a loss or any combination of these effects."
All accidents should be investigated; not just those that result in injury. Any accident
investigation should focus on the multi-causal accident and not uni-causal injury (where
there is one).

The investigation processes
To gather the information (Step 1), the investigators need to ask a series of questions which
aim to tease out all the facts/contributory causes (immediate and underlying) of the accident.

88

They should then analyses the information (Step 2) to establish the facts and chronology of
the events - immediate and underlying - that led to the accident.

The analysis should be specific and unbiased and should identify the sequence of
events/conditions and the combination of causes, using event tree analysis to map out all the
causes in a chronological, logical and linked way.

Specifically, the analysis should clearly establish what happened and why. The investigative
team, ideally three-strong, should identify whether human error or procedural violations
have been contributory factors. It should also identify what other factors contributed to the
accident, whether they are job-related, organizational or linked to plant and equipment.

It's sometimes difficult to pin down the people issues because of the fear of blame
apportionment and/or fault-finding. It's highly unlikely that a supervisor, charged to
investigate an accident on their patch, will come up with "lack of supervision" as one of the
contributory causes. Hence the need for a team of three investigators.

Once you have found all the causal factors and explored all the branches of the event tree to
their ends, then, and only then, can the investigative team get into control mode.

Never discount facts or possible causes that don't fit easily into the picture or the event tree.
These red herrings may be signs of another branch of the event tree that the investigation
has yet to follow. It's usually best to use the term "event tree" rather than "fault tree" as the
latter has definite negative connotations, which have no place in positive accident
investigations.

Control measures
In control mode (Step 3) your team should effectively identify all risk control measures that
were missing, inadequate or misused. They should compare activities, conditions and
practices as they actually were in the run-up to the accident with what should have been in
place according to current best practice, agreed systems of work, legal requirements, and
codes of practice, guidance and standards.

89

The team should identify those extra measures that are required to eliminate all immediate
and underlying causes by providing meaningful recommendations which can be properly
implemented to prevent a recurrence, and hence continually improve the OSH management
system.
Particular questions which may help here include:

 What risk control systems (RCSs) and workplace precautions (WPs) are needed?
 Do similar risks exist elsewhere? If so, what and where?
 Have similar accidents happened before? If so, what and where?
Step 4 - the action plan and its implementation - is the final step in the accident investigation
process. This step should provide a clear action plan with SMARTT objectives (ones that are
specific, measurable, agreed, realistic, time-bound and tractable) to deal effectively with all
the immediate and underlying causes of the accident. It should include lessons that have
been learnt which may be applied to prevent other accidents of a similar type/nature.

The team should also ensure that the results of the investigation are shown to all concerned,
with the emphasis firmly on the resulting action plan, timescales, responsibilities and
accountabilities, and how the plan will be implemented and its progress chased and
monitored.

The risk control action plan should establish which RCSs and WPs should be implemented in
the immediate, short or medium term. The team should also note which risk assessments
and systems of work need to be reviewed, updated and publicized, and whether the accident
details and the resultant findings and recommendations have been recorded and analyzed
from both a numerical and causal viewpoint (that is, reactive monitoring).

They should also flag up whether there are any common causes or trends which suggest the
need for further, deeper and detailed investigation. Finally, they should put a figure on the
overall cost of the accident - both insured and uninsured - and also cost the associated
control measures.

90

Topic Quiz
1. What is an accident?

Types
Physical and non-physical

Physical examples of accidents include unintended motor vehicle collisions or falls, being
injured by touching something sharp, hot, electrical or ingesting poison. Non-physical
examples are unintentionally revealing a secret or otherwise saying something incorrectly,
forgetting an appointment etc.

By activity
Accidents during the execution of work or arising out of it are called work accidents.
According to the International Labour Organization (ILO), more than 337 million accidents
happen on the job each year, resulting, together with occupational diseases, in more than 2.3
million deaths annually.

By vehicle

 Aviation
 Bicycles
 Sailing ships
 Traffic collisions
 Train wrecks
 Trams

Incident

91

Definition of incident

1: something dependent on or subordinate to something else of greater or principal
importance
2 a: an occurrence of an action or situation that is a separate unit of experience: happening
b: an accompanying minor occurrence or condition: concomitant
3: an action likely to lead to grave consequences especially in diplomatic matters a serious
border incident

Difference Between ACCIDENT And INCIDENT

Incident can refer to any event – big or small, good or bad, intentional or unintentional. A
bank robbery, a funny or controversial situation, an argument between celebrities, etc. – all
can be described as incidents.
An accident is a bad event caused by error or by chance. Accidents are always unintentional,
and they usually result in some damage or injury. A car crash is one example of an accident. If
some equipment malfunctions in a factory and injures the workers, that is also an accident.
Examples of very minor accidents are when you step on someone’s foot or spill your coffee
on someone else. You didn’t want or plan to do it.
All accidents can ALSO be described as incidents – but NOT all incidents are accidents.
If a drunk driver runs his car into a group of people, that is an accident (he did not intend to
do it; it was caused by alcohol and chance). It could also be described as an incident (“The
incident occurred on Main Street at around 2:30 AM”).
If three people were arrested after fighting in a bar, that is an incident (but not an accident –
because the fight was not by chance; they intended to fight).

Accident vs. Incident: Don’t Mistake One for the Other

When one watches the news on television or reads the newspapers, one inevitably comes
across the words ‘accident’ and ‘incident’. Because they sound alike, these two words are
thought to be interchangeable by some people – they both end with a ‘-dent’. Furthermore,

92

accident and incident are both used to describe a past, present, or future event. However,
they cannot be used interchangeably – each should be used in certain conditions.

One should understand that ‘incident’ can pertain to any event, whether positive or negative;
a funeral, wedding, forest fire, and classroom session could all be termed as incidents.
Regardless of circumstance, an event can always be termed as an incident. People usually
attach adjectives before the word incident. It’s common to hear phrases such as ‘what an
unfortunate incident’ or ‘it was a good incident’ when people describe events.

On the other hand, the term ‘accident’ cannot be used when describing events in general.
‘Accident’ has a negative implication and points to an unintended or chance event. It can also
pertain to events that involve injury, misfortune, and in some cases even death. To say that a
person accidentally dropped a pen, for example, means that the person unintentionally
dropped the pen. The person may have dropped it because their fingers were sweaty, or
because they fell asleep, or because the pen was too slippery. In any case, the dropping of
the pen was not an intended event; therefore, it can be termed as an accident.

Events such as a train slipping off the rails or an airplane crash-diving into the sea can all be
termed as accidents. In this case, however, the implication is heavy, because these accidents
might involve injury or death. Whether the cause of the event is human error or faulty wiring
or weather, the event can generally be termed as an accident.

Incident Example

93

In the media, any sensational event is automatically termed as an incident; any newsworthy
story can be tagged with the term. For example, a hostage-taking scenario that occurred in
the Philippines can be referred to as ‘the Philippine incident.’ In the same manner, the
awarding ceremony of an actors’ guild can be simply termed as the actors’ ‘guild incident.’
One can observe that the use of this term is very general; it can be used in conjunction with
any significant event.

The trick to effectively differentiating between an accident and an incident is by determining
the nature of the event. All accidents can alternately be called incidents, but not all incidents
are accidents. Events that have negative repercussions and involve any chance electrical
failure or human error should be referred to as accidents. However, events that are positive
in nature should be called incidents.
People should know when to use these two terms in order to avoid misinformation. For
example, using the term ‘accident’ to describe a positive event could cause undue worry and
stress to listeners. In the same way, using the term ‘incident’ to describe a tragedy could
cause listeners to be unaware of the negative implications of the event.

Summary:
1. The terms ‘accident’ and ‘incident’ are used often by the media.
2. ‘Accident’ and ‘incident’ are thought to be interchangeable by some people because
they sound alike; both words end with a ‘-dent’.
3. Both terms can be used to describe a past, present, or future event.
4. Regardless of circumstance, an event can always be termed as an incident.
5. On the other hand, the term ‘accident’ cannot be used when describing events in
general. ‘Accident’ has a negative connotation and points to an unintended or chance
event.
6. All accidents can alternately be called incidents, but not all incidents are accidents.

How to Conduct an Incident Investigation

94

Your company has just experienced an incident resulting in an unintentional injury to a
worker. Now what? Reacting quickly to the incident with a prescribed procedure and actions
can demonstrate your company’s commitment to safety and ensure the proper information
is collected to fulfil an incident investigation’s ultimate purpose – to prevent future incidents.

Steps in an Investigation Process

The investigation process should begin after arranging for first aid or medical treatment for
the injured person(s). In getting started, remind everyone involved—especially workers— the
investigation is to learn and prevent, not find fault. Steps of the investigation process include:
1. Call or gather the necessary person(s) to conduct the investigation and obtain the
investigation kit.
2. Secure the area where the injury occurred and preserve the work area as it is.
3. Identify and gather witnesses to the injury event.
4. Interview the involved worker.
5. Interview all witnesses.
6. Document the scene of the injury through photos or videos.
7. Complete the investigation report, including determination of what caused the incident
and what corrective actions will prevent recurrences.
8. Use results to improve the injury and illness prevention program to better identify and
control hazards before they result in incidents.
9. Ensure follow-up on completion of corrective actions.

What to Include in the Documented Investigation Process

As with many processes, preparation and documentation are crucial. As part of the injury and
illness prevention program, the investigation procedure should detail:
• Who should conduct and participate in the investigation
• Incidents to be investigated
• Information to be collected
• Identification of causal factors (often referred to as root causes)
• Determination of corrective actions

95

• Tracking completion of corrective actions

What is an incident and why should it be investigated?

The term incident can be defined as an occurrence, condition, or situation arising in the
course of work that resulted in or could have resulted in injuries, illnesses, damage to health,
or fatalities.
The term "accident" is also commonly used, and can be defined as an unplanned event that
interrupts the completion of an activity, and that may (or may not) include injury or property
damage. Some make a distinction between accident and incident. They use the term incident
to refer to an unexpected event that did not cause injury or damage that time but had the
potential. "Near miss" or "dangerous occurrence" are also terms for an event that could have
caused harm but did not.
Please note: The term incident is used in some situations and jurisdictions to cover both an
"accident" and "incident". It is argued that the word "accident" implies that the event was
related to fate or chance. When the root cause is determined, it is usually found that many
events were predictable and could have been prevented if the right actions were taken -
making the event not one of fate or chance (thus, the word incident is used). For simplicity,
we will now use the term incident to mean all of the above events.
The information that follows is intended to be a general guide for employers, supervisors,
health and safety committee members, or members of an incident investigation team. When
incidents are investigated, the emphasis should be concentrated on finding the root cause of
the incident so you can prevent the event from happening again. The purpose is to find facts
that can lead to corrective actions, not to find fault. Always look for deeper causes. Do not
simply record the steps of the event.
Reasons to investigate a workplace incident include:

 most importantly, to find out the cause of incidents and to prevent similar incidents in
the future

 to fulfil any legal requirements
 to determine the cost of an incident
 to determine compliance with applicable regulations (e.g., occupational health and

safety, criminal, etc.)

96

 to process workers' compensation claims
The same principles apply to an inquiry of a minor incident and to the more formal
investigation of a serious event. Most importantly, these steps can be used to investigate any
situation (e.g., where no incident has occurred ... yet) as a way to prevent an incident.

Who should do the investigating?

Ideally, an investigation would be conducted by someone or a group of people who are:
 experienced in incident causation models,
 experienced in investigative techniques,
 knowledgeable of any legal or organizational requirements,
 knowledgeable in occupational health and safety fundamentals,
 knowledgeable in the work processes, procedures, persons, and industrial relations
environment for that particular situation,
 able to use interview and other person-to-person techniques effectively (such as
mediation or conflict resolution),
 knowledgeable of requirements for documents, records, and data collection; and
 able to analyse the data gathered to determine findings and reach recommendations.

Some jurisdictions provide guidance such as requiring that the incident must be conducted
jointly, with both management and labour represented, or that the investigators must be
knowledgeable about the work processes involved.
Members of the team can include:

 employees with knowledge of the work
 supervisor of the area or work
 safety officer
 health and safety committee
 union representative, if applicable
 employees with experience in investigations
 "outside" experts
 representative from local government or police

Should the immediate supervisor be on the team?

97

The advantage is that this person is likely to know most about the work and persons involved
and the current conditions. Furthermore, the supervisor can usually take immediate remedial
action. The counter argument is that there may be an attempt to gloss over the supervisor’s
shortcomings in the incident. This situation should not arise if the incident is investigated by a
team of people, and if the worker representative(s) and the investigation team members
review all incident investigation findings and recommendations thoroughly.

Why look for the root cause?

An investigator or team who believe that incidents are caused by unsafe conditions will likely
try to uncover conditions as causes. On the other hand, one who believes they are caused by
unsafe acts will attempt to find the human errors that are causes. Therefore, it is necessary
to examine all underlying factors in a chain of events that ends in an incident.
The important point is that even in the most seemingly straightforward incidents, seldom, if
ever, is there only a single cause. For example, an "investigation" which concludes that an
incident was due to worker carelessness, and goes no further, fails to find answers to several
important questions such as:

 Was the worker distracted? If yes, why was the worker distracted?
 Was a safe work procedure being followed? If not, why not?
 Were safety devices in order? If not, why not?
 Was the worker trained? If not, why not?
An inquiry that answers these and related questions will probably reveal conditions that are
more open to correction.

What are the steps involved in investigating an incident?
First:

 Report the incident occurrence to a designated person within the organization.
 Provide first aid and medical care to injured person(s) and prevent further injuries or

damage.
The incident investigation team would perform the following general steps:

98

 Scene management and scene assessment (secure the scene, make sure it is safe for
investigators to do their job).

 Witness management (provide support, limit interaction with other witnesses,
interview).

 Investigate the incident, collect data.
 Analyse the data, identify the root causes.
 Report the findings and recommendations.
The organization would then:
 Develop a plan for corrective action.
 Implement the plan.
 Evaluate the effectiveness of the corrective action.
 Make changes for continual improvement.
As little time as possible should be lost between the moment of an incident and the
beginning of the investigation. In this way, one is most likely to be able to observe the
conditions as they were at the time, prevent disturbance of evidence, and identify witnesses.
The tools that members of the investigating team may need (pencil, paper, camera or
recording device, tape measure, etc.) should be immediately available so that no time is
wasted.

What should be looked at as the cause of an incident?
Causation Models

Many models of causation have been proposed, ranging from Heinrich's domino theory to
the sophisticated Management Oversight and Risk Tree (MORT).
The simple model shown in Figure 1 attempts to illustrate that the causes of any incident can
be grouped into five categories - task, material, environment, personnel, and management.
When this model is used, possible causes in each category should be investigated. Each
category is examined more closely below. Remember that these are sample questions only:
no attempt has been made to develop a comprehensive checklist.
Figure 1: Incident Categories

99

Task

Here the actual work procedure being used at the time of the incident is explored. Members
of the investigation team will look for answers to questions such as:

 Was a safe work procedure used?
 Had conditions changed to make the normal procedure unsafe?
 Were the appropriate tools and materials available?
 Were they used?
 Were safety devices working properly?
 Was lockout used when necessary?
For most of these questions, an important follow-up question is "If not, why not?"

Material

To seek out possible causes resulting from the equipment and materials used, investigators
might ask:

 Was there an equipment failure?
 What caused it to fail?
 Was the machinery poorly designed?

100