Hazards-related incident

OBSERVATIONS ON CAUSATION MODELS FOR HAZARDS-RELATED INCIDENTS 3... 

If several safety professionals investigate a given hazards-related incident, they should identify the same causal factors, with minimum variation. That is unlikely if the thought processes they use have greatly different foundations. At least 25 causation models have been published. Since many of them conflict, all of them cannot be valid. A review of some of them is followed by a discussion of principles that should be contained in a causation model. 

A SYSTEMIC CAUSATION MODEL FOR HAZARDS-RELATED INCIDENTS... 

An organization s culture determines the level of safety to be obtained. What the board of directors or senior management decides is acceptable for the prevention and control of hazards is a reflection of its culture. Management attains, as a derivation of its culture, the hazards-related incident experience it estabhshes as tolerable. For personnel in an organization, tolerable is their interpretation of what management does. This phrase is often heard You will achieve the level of safety that you demonstrate you want to achieve. 

Where hazards are given the required consideration in the design and engineering processes, a foundation is established that gives good probability to favorable hazards-related incident avoidance. Also, the potentially large expenses of retrofitting are thus avoided. 

Far greater use is being made of incident investigation teams. Safety professionals say that the time expended by those teams is a worthwhile investment since the activity communicates management s intent to avoid hazards-related incidents. Over time, large numbers of personnel are involved. 

Risk is defined as a measure of the probability of a hazards-related incident occurring and the severity of harm or damage that conld resnlt. 

In the operational mode — where, integrated within a continuous improvement process, hazards are identified and evaluated and eliminated or controlled, before their potentials are realized and hazards-related incidents occur. 

Post incident—through investigation of hazards-related incidents to determine and eliminate or control their causal factors. 

If a hazard is not avoided, eliminated, or controlled, its potential may be realized, and a hazards-related incident may occur that will or will not result in harm or damage, depending on exposures. 

A hazard-related incident, a HAZRIN, is an unplanned, unexpected process of multiple and interacting events, deriving from the realization of uncontrolled hazards and occurring in sequence or in parallel, that is likely to result in harm or damage. 

Hazards-related incidents, even the ordinary and frequent, are complex and have multiple and interacting causal factors. 

Management obtains, as a derivation of its culture — as an extension of its system of expected behavior—the hazards-related incident experience that it establishes as tolerable. For personnel in the organization, tolerable is their interpretation of what management does. 

Extrapolating from Deming, a large majority of the causal factors for hazards-related incidents are systemic, and a small minority will be principally employee-focused. 

For most all hazards-related incidents, even those that seem to present the least complexity, there are multiple causal factors that derive from less than adequate workplace and work methods design engineering, management and operations, and personnel task performance practices. 

In the hazards-related incident process, deriving from those multiple causal factors ... 

Severity potential should determine whether hazards-related incidents should be considered signifieant, even though serious harm or damage did not occur. 

For years, safety practitioners have sought soundly based methods to communicate to management on the reality of hazards-related incident costs. That would be great to have. 

A safety professional who gives advice on avoiding, eliminating, or controlling hazards in any of the three elements in the practice of safety (preoperational, operational, and post-incident) must understand how hazards-related incidents occur to be effective. It is basic in problem solving to define and understand the problem, to analyze the cause-and-effect relationships of the subsets of the problem, to consider alternate solutions, to choose and apply the solutions, and to subsequently evaluate their efficacy. 

This chapter addresses the need for safety professionals to adopt an incident causation model, a thought process based on a sound understanding of the hazards-related incident phenomenon and which, when applied, identifies the reality of the causal factors in the incident process. 

At the Safety Technology 2000 symposium held by the American Society of Safety Engineers in June of 1995, many of the papers presented made specific reference to or alluded to an accident causation concept. From a review of those papers, it was obvious that the beliefs of safety professionals about concepts of hazards-related incident causation are far from consensus. These are the extremes in the variations expressed on incident causation in those papers ... 

Assume that a given hazards-related incident is to be investigated. Safety professionals who have adopted, and give prominence and near exclusivity to, one or the other of those concepts would give greatly divergent remediation advice. The advice deriving from a narrow application of either approach would not address all of the causal factors, nor would the remedial actions proposed achieve the needed risk reduction. 

If we who call ourselves safety professionals are to be tmly perceived as professionals, we must resolve this matter of a generally accepted hazards-related incident causation model. A major study on this subject would be to our advantage. 

As used in this treatise, causation means the act or agency of causing or producing an effect. Causal factors include all of the elements — the events, the characteristics of things, and the actions or inactions of persons— that contribute to the incident process. A model is to represent the theoretical ideal for the process through which hazards-related incidents occur, a process that requires determining when the phenomenon begins and ends. 

Safety professionals give many names to the incidents to which a causation model would apply accidents, incidents, mishaps, near-misses, occurrences, events, illnesses, fires, explosions, windstorms, drownings, electrocutions, and so on. Pat Clemens, a prominent safety consultant, has said that the language used by safety practitioners lacks words to convey precise and understood meanings. It s probable that the people with whom safety professionals try to eommunicate are baffled by the many terms used to describe hazards-related incidents. 

Severity potential for harm or damage should determine whether a hazards-related incident is to be given priority consideration. Categorizing incidents that result in harm or damage separately from those that do not, even though the results of the latter could have been severe under slightly different circumstances, too often results in misapplication of resources. 

So, it is proposed that a new name be created to encompass all hazards-related incidents—HAZRINS. The term HAZRIN encompasses all incidents that are the realization of the potential for harm or damage, whether harm or damage resulted or could have resulted, for all fields of endeavor that are hazards-related. 

A sound causation model for hazards-related incidents must identify and stress the significance of the design management aspects and the operations management aspects and the task performance aspects... 

It s proposed that safety professionals can benefit from a review of the causation models on which their practices are based. For those who would undertake such an exercise toward the development of an acceptable causation model for hazards-related incidents, the following are recommended as noinimal readings ... 

There are significant commonalities and differences in these publications. My intent is to select from them to support a logical thought process, and add my own views. To begin with, a hazards-related incident, a HAZRIN, should have a definition. 

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