LP News issue 17 - UK P&I Members Area

ManageSimple event chain or incident trajectoryequation but very quickly established an‘alternative’ theory of accident causation.FIRST EVENT SECOND SET OF EVENTS FINAL EVENT Because of the triangular shape of the(ACCIDENT)basic model of the theory, it becameHAZARD(ineffectiveknown as the ‘Tripodian’ view of accidentTARGETaftercare)EVENTcausation. Basically it uses the(operator)(partial disability)‘conventional’ diagram shown below, left,HAZARDEVENT-TARGET(ignition source)(operator-burned)but adds a third component general failureEVENT-HAZARDtypes (GFTs).(fire)TARGETEVENTThis ‘alternative’ model of accident(flammable(equipmentmaterial)damaged)TARGETcausation is shown in the diagram below.(equipment)The research accepts that, properlyinvestigated, there is much in a reactivesense to be learnt from accidents. It alsoaccidents continuedThe concept of the ‘event chain’ or‘incident trajectory’ is shown above.Note the original (first) event resulted ina fire. In the presence of two new‘targets’, i.e. an operator and a piece ofequipment, the resultant double event ledwill invariably have been caused by the actsor omissions of people, which may benothing more than a simple andunintentional mistake. Such unsafe acts orunsafe conditions are generally referred toas active failures.recognises, that unsafe acts or activefailures can be reduced using tools aimedat modifying human behaviour. Theresearch suggested that the problem withattempting to learn solely from activefailures is that; (a) there are potentiallyto a badly burnt operator (injury) andWhile active failuresdamaged equipment (asset damage). are interesting –Accident causation – the ‘Tripodian view’Because the immediate aftercare of theinjured operator (first aid or paramedicindeed much can belearnt from them – aGeneraltreatment) was ineffective (new hazard), lot more can be learnt,failurethe operator’s injuries resulted in a partial and more effectiveReducetypesdisability (final event).remedial measures putHazardsReverting to the simple accident in place, by addressingdiagram and the ‘formula’ in the text box the sick camel in theon the front page, if one of the controls or first place.Accidentsdefences had not been breached there ConventionalUnsafe acts IncidentsLTIs etcwould not have been an accident. If wisdom (below, left),detected, the resultant ‘near-miss’ or dictates that in orderLearn from‘dangerous occurrence’ could still have for an accident toSpecificsituationsbeen reported, investigated and acted happen, defences ofDefencesupon as if it were the real thing.The usual mechanism, whereby controlsand defences are breached, is an unsafeact by an individual at the sharp end.Occasionally, they may be breached by aninherent unsafe condition but these toosome kind will havebeen breached, usuallyby an unsafe act, carried out in a specificsituation and in the presence of hazards ofsome kind.What changed this long-establishedview, which as a basismillions of them; (b) they will rarely berepeated in the same way, and; (c) thecircumstances in which they occurred willnever be exactly the same. Moreimportantly the research established onceAccident causation – the ‘conventional view’Hazardsfor the new model isstill correct, was somehighly originalresearch sponsored byone of the oil-majorsand for all that the ‘sick camel’ could bemade considerably healthier by managingwhat are called the general failure types(GFTs) of which there are just eleven. Usinga medical analogy, the GFTs could beUnsafe actsand carried out at two considered as the vital organs of theAccidentsmajor universities, oneIncidents‘safety body’. If properly managed in termsLTIs etc in the UK and one in of their inherent health or strength, thesethe Netherlands. The could actually help prevent large numbersSpecificresearch originally set of accidents from ever happening at all.situationsDefencesout to establish the Once again, in medical terms it’s a bit likerole of the humanbeing in the accidenthaving a healthy heart and preventingheart attacks, or being vaccinated against2