High Risk Acts and Conditions

Numerous accidents are a result of a combination of high risk acts and high risk conditions (National Safety Council, 2010). Very seldom does one isolated act or condition ever result in an accident. Multiple causes are nearly always present in the accident sequence. 

In the United States, machinery is one of the top four sources of compensable work injuries and accounts for nearly 10 percent of all injuries. The other sources are manual handling accidents, which cause 23 percent of all injuries falls, 20 percent and struck by falling or moving objects, 14 percent. 

Although the high risk acts or conditions may be the most prominent factor that cause the accident, the identification and remedy must not stop there. A thorough investigation must be done to determine why the high risk act took place or why the high risk condition exists. This query will inevitably identify the root causes that must be eradicated. 

For example, A worker was walking on the factory floor when he stepped in and slipped on a puddle of oil. Upon investigation, it was obvious that the accident and consequent injury was caused by the oil on the walkway, which rendered the floor slippery and unsafe. 

Wiping up the oil is a good way of preventing a recurrence of the same type of accident, but will not solve the problem. After wiping up the oil, one may discover another patch of oil farther down the walkway. Cleaning that up will also only be rectifying immediate causes and not the basic reason for the high risk condition. 

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While the near miss incidents that form the base of the accident ratio are truly the foundation of a major injury, numerous high risk acts and conditions lie below on the next level (Model 1.2). Research has indicated that this lower level of unsafe situations could equate to as many as a thousand high risk situations for every serious injury experienced. While the actual numbers are debatable, the fact remains that there must be numerous high risk acts and conditions for the plenty of near miss incidents experienced. 

You cannot eliminate high risk acts and conditions until you have effective control measures in the form of a structured safety management system. 

Near miss incident recall also can offer a guide as to what training is needed concerning the high risk acts and conditions that are being reported. It can help to... 

High risk acts and conditions are the immediate causes of accidents. They are the obvious causes, or the causes that lead to the contact with a source or sources of energy. Immediate causes are the result of often deep-lying root causes. 

High potential near miss incidents indicate a failure of the safety management system and are warnings that under different circumstances a loss could be caused by a similar failure. Reducing the number of near miss incidents helps reduce the numerous high risk acts and conditions lying beneath the surface. Remedying near miss causes will lead to a reduction in injuries and help develop a positive safety culture. 

Management at all levels is then held accountable to rectify the problems identified by the safety system and to ensure that the high-risk acts or conditions highlighted by the system are rectified before a loss event occurs. 

Fortune, chance, or luck plays a major role in determining the outcome of high-risk acts and high-risk conditions. 

A near miss incident must have an energy phase or there is no near miss scenario. A high risk act or condition does not constitute a near miss incident if there is not a flow of energy that could have contacted. They should be reported and acted upon, anyway. 

Numerous high risk acts are committed daily, but do not result in a contact of any sort. These are not near miss incidents as there has been no flow of energy that, in a contact situation, would have caused injury, damage, or other loss. Many confuse the high risk act and the high risk condition with near miss incidents. To fall into the latter category, there must be a flow of energy. 

The near miss incident system should not restrict the employees to reporting only near miss incidents. As they are so closely related, reports of high risk work environments and high risk practices should be encouraged as well. Many near miss reports, in fact, will be high risk acts or conditions, but the reporters should not be discouraged from reporting if they are not pure near miss incidents as per definition. Any hazard reported is an opportunity to prevent loss. 

Near miss incident and accident investigation also indicates who was involved at the time of the event and, most importantly, is a means to identify the immediate causes in the form of high risk acts and high risk conditions. Once these are determined, they enable us to establish the root cause or basic causes of the occurrence. Near miss incidents reveal the same information as accidents because the same factors that contribute to them are present in the near miss situation. 

The immediate causes of accidents and near miss incidents are the high risk acts and high risk conditions and once determined lead to identification of the root causes in the form of personal factors and job factors. 

Root, or basic, causes are the deep hidden person and job factors that give rise to the immediate causes in the form of high risk acts and/or conditions. If they are not identified and rectified, the accident problem will not be eliminated. Fixing the immediate causes rectifies the symptom, but not the root or basic cause. 

The immediate causes of accidents are circumstances that immediately precede the contact with the source and flow of energy. They usually can be seen or sensed. Frequently they are called unsafe acts (behaviors that could permit the occurrence of an accident) and unsafe conditions (circumstances that could permit the occurrence of an accident). Modern managers tend to think a bit more broadly, and more professionally, in terms of high-risk practices and high-risk conditions, which are defined as deviations from an accepted standard or practice. 

Patient safety has become a key value for our entire organization and the foundation of our operations. Patient safety is everyone s job. High-risk processes and procedures are analyzed to detect vulnerabilities and failure points that could contribute to an accident. Employees are engaged in anticipating where the next failure or accident may occur and are empowered to act in the interest of restoring safety if they perceive that we are moving into conditions of intolerable risk. Local teams operate with simple rules Fix what you can. Tell what you fixed. Find someone to fix what you cannot. ... 

The majority of undesired events (high risk acts, high risk conditions, and near miss incidents) do not end up in injury. Less than 1 percent of all undesired events result in serious injury (injury-producing accidents), approximately 2 percent result in minor injury, and about 5 percent cause damage to property, material, and the environment. Based on the Bird-Germain (1992) 1 10 30 600 ratio, the majority are ranked as near miss incidents. 

The basic (root) causes of accidents are categorized as personal and job factors. They are the underlying reasons why high risk acts are committed and why high risk conditions exist. A personal factor conld be a lack of skill, physical or mental incapability to carry out the work, poor attitude, or lack of motivation. Job factors conld include inadequate purchasing, poor maintenance, incorrect tools, or inad-eqnate equipment. 

These basic causes then trigger the immediate causes that are unsafe work conditions and unsafe work practices (high risk conditions and high risk acts). 

Fires are devastating. Every year, millions of dollars worth of property and products are destroyed. Fires are undesired events and occur as a result of high risk acts, high risk conditions. Property damage caused by fires is overwhelming. Instances can occur where the fire causes no injuries, in which case, the only consequence is damage to property, machinery, and products. 

Once a high risk act has been committed, the outcome (or result) of this act depends largely on chance, good or bad fortune, or luck. This is termed Luck Factor 1. A high risk condition is a hazard and can result in a number of outcomes depending on Luck Factor 1. 

You cannot be near miss incident-free unless you have no high risk conditions and no high risk acts are committed. 

Many organizations show specific safety DVDs to remind employees of past accidents in an effort to raise awareness. The showing of a film, and relating it to, either a near miss incident, or accident recall, is a good idea. Safety DVDs often have high risk acts or high risk conditions portrayed and these scenes could act as reminders and prompts for the accident or near miss incident recall session. 

It is vital that some form of feedback and follow up on the reported near miss incidents is given. Generally, a monthly list of all the items reported is circulated to all via the intranet or posted on the notice boards, or featured in the newsletter. Employees want to see what they have reported in writing and want to see some form of action being taken on their report. In most instances, the reports will be of high risk acts or high risk conditions and safe work observations and few may be true near miss incidents. 

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