NEBOSH INTERNATIONAL DIPLOMA
UNIT IA
UNIT IA: INTERNATIONAL MANAGEMENT OF
HEALTH AND SAFETY
NEBOSH INTERNATIONAL DIPLOMA
UNIT IA: INTERNATIONAL MANAGEMENT OF
HEALTH AND SAFETY
CONTRIBUTORS
Dr Terry Robson, Bsc (Hons), PhD, CFIOSH, MRSC, CChem
ACKNOWLEDGMENTS
© RRC International
All rights reserved. RRC International is the trading name of The Rapid
Results College Limited, Tuition House, 27-37 St George’s Road,
London, SW19 4DS, UK.
These materials are provided under licence from The Rapid Results
College Limited. No part of this publication may be reproduced, stored in
a retrieval system, or transmitted in any form, or by any means, electronic,
electrostatic, mechanical, photocopied or otherwise, without the express
permission in writing from RRC Publishing.
For information on all RRC publications and training courses, visit:
www.rrc.co.uk
RRC: NIDA.1
ISBN: 978-1-909055-53-7 First edition Spring 2015
RRC International would like to thank the National Examination Board
in Occupational Safety and Health (NEBOSH) for their co-operation in
allowing us to reproduce extracts from their syllabus guides.
This publication contains public sector information published by the Health
and Safety Executive and licensed under the Open Government Licence v.2
(www.nationalarchives.gov.uk/doc/open-government-licence/version/2).
Every effort has been made to trace copyright material and obtain
permission to reproduce it. If there are any errors or omissions, RRC would
welcome notification so that corrections may be incorporated in future
reprints or editions of this material.
Whilst the information in this book is believed to be true and accurate at
the date of going to press, neither the author nor the publisher can accept
any legal responsibility or liability for any errors or omissions that may be
made.
Contents
UNIT IA
INTRODUCTION
ELEMENT IA1: PRINCIPLES OF HEALTH AND SAFETY MANAGEMENT
REASONS FOR MANAGING HEALTH AND SAFETY
Moral
Legal
Economic
Revision Question
1-3
1-3
1-3
1-4
1-4
SOCIETAL FACTORS WHICH INFLUENCE HEALTH AND SAFETY STANDARDS AND PRIORITIES
Significant Factors
Principle of Corporate Social Responsibility
Revision Question
1-5
1-5
1-6
1-6
INTRODUCTION TO MANAGEMENT SYSTEMS
Definitions
Key Elements of an Effective Health and Safety Management System
Principles and Benefits of Risk Management on a Global Perspective
Organisational Models for Health and Safety Management
Benefits and Limitations of Integrated Management Systems
Key Typical Components of OHS Management Systems
Quality and Environmental Management Systems
Arguments For and Against Integration of Management Systems
Reasons for the Introduction of Formal Health and Safety Management Systems
Role of the Health and Safety Policy
Requirements for a Written Health and Safety Policy and for Recording Arrangements
General Principles and Objectives of a Health and Safety Policy Document
Common Health and Safety Management Systems in Global Organisations
Influence of Corporate Responsibility and Business Ethics
Role of Health and Safety in Global Corporate Social Responsibility (CSR) Guidelines and Standards
Revision Questions
1-8
1-8
1-8
1-8
1-9
1-12
1-13
1-14
1-16
1-16
1-17
1-18
1-18
1-18
1-19
1-19
1-21
ROLE AND RESPONSIBILITIES OF THE HEALTH AND SAFETY PRACTITIONER
Influence on Health and Safety Management Systems
Health and Safety Involvement and Conduct
Competence and the Requirements for Continuing Professional Development
Responsibility to Evaluate and Develop Their Own Practice
Ethics and the Application of Ethical Principles
Dealing with Conflicts of Interest
Revision Questions
1-22
1-22
1-23
1-23
1-23
1-24
1-25
1-25
SUMMARY
1-26
EXAM SKILLS
1-28
Contents
ELEMENT IA2: LOSS CAUSATION AND INCIDENT INVESTIGATION
THEORIES OF LOSS CAUSATION
Accident/Incident Ratio Studies
Domino and Multi-Causality Theories
Immediate, Underlying and Root Causes
Reason’s Model of Accident Causation
Revision Questions
2-3
2-3
2-4
2-7
2-8
2-9
QUANTITATIVE ANALYSIS OF ACCIDENT AND ILL-HEALTH DATA
Calculating Loss Rates from Raw Data
Statistical and Epidemiological Analyses in the Identification of Patterns and Trends
Presenting and Interpreting Loss Event Data
Principles of Statistical Variability, Validity and the Use of Distributions
Revision Question
2-10
2-10
2-11
2-11
2-15
2-16
REPORTING AND RECORDING OF LOSS EVENTS (INJURIES, ILL HEALTH, DANGEROUS OCCURRENCES)
AND NEAR MISSES
Reporting Requirements and Procedures
Internal Reporting and Recording
Revision Questions
2-17
2-17
2-19
2-27
LOSS AND NEAR-MISS INVESTIGATIONS
Purposes of Accident Investigation
Investigation Procedures and Methodologies
Communications Focusing on Remedial Actions and Lessons Learnt
Use of Failure Tracing Methods as Investigative Tools
Revision Questions
2-28
2-28
2-30
2-34
2-34
2-34
SUMMARY
2-35
EXAM SKILLS
2-37
Contents
ELEMENT IA3: MEASURING AND REVIEWING HEALTH AND SAFETY PERFORMANCE
PURPOSE OF PERFORMANCE MEASUREMENT
Assessment of the Health and Safety Objectives and Arrangements
Review of Current Management Systems
Revision Question
3-3
3-3
3-6
3-7
MONITORING SYSTEMS
Need for Active and Reactive Measures
Objectives of Monitoring
Limitations of Accident and Ill-Health Data as a Performance Measure
Distinctions Between, and Applicability of, Performance Measures
Revision Questions
3-8
3-8
3-8
3-9
3-9
3-10
MONITORING AND MEASUREMENT TECHNIQUES
Range of Measures Available to Evaluate an Organisation’s Performance
Key Elements and Features of Measurement Techniques
In-House and Proprietary Audit Systems
Use of Computer Technology to Assist with Data Storage and Analysis and Production of Reports
Comparisons of Performance Data
Use of Benchmarking
Revision Questions
3-11
3-11
3-12
3-13
3-13
3-15
3-15
3-16
REVIEWING HEALTH AND SAFETY PERFORMANCE
Formal and Informal Reviews of Performance
Review Process
Revision Question
3-17
3-17
3-17
3-18
SUMMARY
3-19
EXAM SKILLS
3-21
Contents
ELEMENT IA4: IDENTIFYING HAZARDS, ASSESSING AND EVALUATING RISKS
SOURCES OF INFORMATION TO SUPPORT HAZARD IDENTIFICATION AND RISK ASSESSMENT
Accident/Incident and Ill-Health Data and Rates
External Information Sources
Internal Information Sources
Uses and Limitations of Information Sources
Revision Questions
4-3
4-3
4-4
4-4
4-4
4-5
HAZARD IDENTIFICATION TECHNIQUES
Hazard Detection Techniques
Importance of Worker Input
Revision Question
4-6
4-6
4-7
4-7
ASSESSMENT AND EVALUATION OF RISK
Key Steps in a Risk Assessment
Temporary Situations
Types of Risk Assessment
Organisational Arrangements for an Effective Risk Assessment Programme
Acceptability/Tolerability of Risk
Revision Questions
4-8
4-8
4-11
4-11
4-13
4-14
4-15
FAILURE TRACING METHODOLOGIES
A Guide to Basic Probability
Principles and Techniques of Failure Tracing Methods in the Assessment of Risk
Revision Questions
4-16
4-16
4-17
4-29
SUMMARY
4-30
EXAM SKILLS
4-32
Contents
ELEMENT IA5: RISK CONTROL
COMMON RISK MANAGEMENT STRATEGIES
Concepts Within a Health and Safety Management Programme
Selection of Optimum Solution Based on Relevant Risk Data
Revision Question
5-3
5-3
5-6
5-7
FACTORS TO BE TAKEN INTO ACCOUNT WHEN SELECTING RISK CONTROLS
General Principles of Prevention
Categories of Control Measures
General Hierarchy of Control Measures
Factors Affecting Choice of Control Measures
Cost-Benefit Analysis
Revision Questions
5-8
5-8
5-10
5-10
5-11
5-11
5-13
SAFE SYSTEMS OF WORK AND PERMIT-TO-WORK SYSTEMS
Safe Systems of Work
Use of Risk Assessment in Developing and Implementing a Safe System of Work
Permit-to-Work Systems
Revision Questions
5-14
5-14
5-16
5-17
5-22
SUMMARY
5-23
EXAM SKILLS
5-24
Contents
ELEMENT IA6: ORGANISATIONAL FACTORS
INTERNAL AND EXTERNAL INFLUENCES
Internal Influences on Health and Safety Within an Organisation
External Influences on Health and Safety Within an Organisation
Revision Questions
6-3
6-3
6-5
6-6
TYPES OF ORGANISATIONS
Concept of the Organisation as a System
Organisational Structures and Functions
Organisational Goals and Those of the Individual: Potential Conflict
Revision Question
6-7
6-7
6-7
6-11
6-12
THIRD PARTY CONTROL
Integration of Goals of the Organisation with the Needs of the Individual
Identification of Third Parties
Reasons for Ensuring Third Parties are Covered by Health and Safety Management Systems
Basic Duties Owed To and By Third Parties
Selection, Appointment and Control of Contractors
Responsibilities for Control of Risk Associated with Contractors on Site
Revision Questions
6-12
6-12
6-13
6-13
6-14
6-15
6-16
6-16
CONSULTATION WITH WORKERS
Provision of Information Relating to Hazards/Risks to Third Parties
Role of Consultation Within the Workplace
Formal Consultation
Informal Consultation
Role of the Health and Safety Practitioner in the Consultative Process
Behavioural Aspects Associated with Consultation
Development of Positive Consultative Processes
Revision Questions
6-16
6-16
6-17
6-18
6-19
6-20
6-20
6-21
6-22
HEALTH AND SAFETY MANAGEMENT INFORMATION SYSTEM
Health and Safety Management Information Systems Within the Workplace
Types of Data Within a Health and Safety Management Information System
Requirements and Practical Arrangements for Providing Health and Safety Information
Revision Questions
6-23
6-23
6-24
6-25
6-25
HEALTH AND SAFETY CULTURE AND CLIMATE
Culture and Climate
Impact of Organisational Cultural Factors on Individual Behaviour
Indicators of Culture
Correlation Between Health and Safety Culture/Climate and Health and Safety Performance
Measurement of the Culture and Climate
Revision Questions
6-26
6-26
6-27
6-28
6-28
6-28
6-30
FACTORS AFFECTING HEALTH AND SAFETY CULTURE AND CLIMATE
Promoting a Positive Health and Safety Culture
Factors that May Promote a Negative Health and Safety Culture or Climate
Effecting Cultural or Climate Change
Problems and Pitfalls Relating to Change
Revision Questions
6-31
6-31
6-32
6-33
6-35
6-35
SUMMARY
6-36
EXAM SKILLS
6-38
Contents
ELEMENT IA7: HUMAN FACTORS
HUMAN PSYCHOLOGY, SOCIOLOGY AND BEHAVIOUR
Meaning of Terms
Influences on Human Behaviour
Key Theories of Human Motivation
Factors Affecting Behaviour
On-Line and Off-Line Processing
Knowledge-, Rule- and Skill-Based Behaviour (Rasmussen)
Revision Questions
7-3
7-3
7-3
7-3
7-5
7-7
7-7
7-9
PERCEPTION OF RISK
Human Sensory Receptors
Process of Perception of Danger
Errors in Perception Caused by Physical Stressors
Perception and the Assessment of Risk
Perception and Sensory Inputs
Individual Behaviour in the Face of Danger
Revision Questions
7-10
7-10
7-11
7-11
7-12
7-12
7-14
7-16
HUMAN FAILURE CLASSIFICATION
HSG48, Classification of Human Failure
Contribution of Human Error to Serious Incidents
Revision Question
7-17
7-17
7-20
7-24
IMPROVING INDIVIDUAL HUMAN RELIABILITY IN THE WORKPLACE
Motivation and Reinforcement
Selection of Individuals
Revision Question
7-25
7-25
7-26
7-27
ORGANISATIONAL FACTORS
Effect of Weaknesses in the Safety Management System on the Probability of Human Failure
Influence of Safety Culture on Behaviour and Effect of Peer Group Pressures and Norms
Influence of Formal and Informal Groups
Organisational Communication Mechanisms and their Impact on Human Failure Probability
Procedures for Resolving Conflict and Introducing Change
Revision Questions
7-28
7-28
7-29
7-30
7-33
7-37
7-37
JOB FACTORS
Effect of Job Factors on the Probability of Human Error
Application of Task Analysis
Role of Ergonomics in Job Design
Ergonomically-Designed Control Systems
Relationship Between Physical Stressors and Human Reliability
Effects of Fatigue and Stress on Human Reliability
Revision Questions
7-38
7-38
7-39
7-39
7-42
7-43
7-44
7-44
BEHAVIOURAL CHANGE PROGRAMMES
Principles of Behavioural Change Programmes
Organisational Conditions Needed for Success in Behavioural Change Programmes
Example of Typical Behavioural Change Programme Contents
Revision Question
7-45
7-45
7-46
7-47
7-48
SUMMARY
7-49
EXAM SKILLS
7-52
Contents
ELEMENT IA8: REGULATING HEALTH AND SAFETY
COMPARATIVE GOVERNMENTAL AND SOCIO-LEGAL AND CORPORATE REGULATORY MODELS
8-3
Role, Function and Limitations of Legislation
8-3
Nature, Benefits and Limitations of ‘Goal-Setting’ and ‘Prescriptive’ Legal Models
8-4
Loss Events in Terms of Failures in the Duty of Care to Protect Individuals and Compensatory Mechanisms that May be
Available
8-5
Mechanisms Used to Enforce Health and Safety Legislation
8-8
Laws of Contract
8-10
Revision Questions
8-11
ROLE AND LIMITATIONS OF THE INTERNATIONAL LABOUR ORGANISATION IN A GLOBAL HEALTH
AND SAFETY SETTING
8-12
Role and Status of Ratified Conventions, Recommendations and Codes of Practice in Relation to Health and Safety
8-12
Roles and Responsibilities of ‘National Governments’, ‘Enterprises’ and ‘Workers’: R164 Occupational Safety and Health
Recommendation 1981
8-14
Use of International Conventions as a Basis for Setting National Systems of Health and Safety Legislation
8-15
Revision Questions
8-15
ROLE OF NON-GOVERNMENTAL BODIES AND HEALTH AND SAFETY STANDARDS
8-16
Relevant Influential Parties
8-16
Importance of the Media in a Global Economy
8-17
Benefits of Schemes Which Promote Co-Operation on Health and Safety Between Different Companies
8-18
Effects on Business of Adverse Stakeholder Reaction to Health and Safety Concerns
8-18
Origins and Meaning of ‘Self-Regulation’
8-19
Role and Function of Corporate Governance in a System of Self-Regulation
8-20
How Internal Rules and Procedures Regulate Health and Safety Performance
8-21
How Non-Conformity to an Accredited Health and Safety Standard can be Used as a Form of Enforcement Within a SelfRegulatory Model
8-22
Revision Questions
8-23
SUMMARY
8-24
EXAM SKILLS
8-25
REVISION AND EXAMINATION
SUGGESTED ANSWERS
Introduction
COURSE STRUCTURE
UNIT IA
This textbook has been designed to provide the reader
with the core knowledge needed to successfully complete
the NEBOSH International Diploma in Occupational
Health and Safety, as well as providing a useful overview of
health and safety management. It follows the structure and
content of the NEBOSH syllabus.
The NEBOSH International Diploma consists of four
units of study. When you successfully complete any of the
units you will receive a Unit Certificate, but to achieve a
complete NEBOSH Diploma qualification you need to pass
the three units within a five-year period. For more detailed
information about how the syllabus is structured, visit the
NEBOSH website (www.nebosh.org.uk).
Assessment
Unit IA is assessed by a two-part, three-hour exam. Section
A consists of six 10-mark compulsory questions, and
Section B consists of five 20-mark questions, of which you
must choose three.
NEBOSH set and mark this exam paper.
International Management of
Health and Safety
UNIT IB
International Management of Hazardous
Agents in the Workplace
UNIT IC
International Workplace and Work
Equipment Safety
UNIT ID
Application of International Health and
Safety Theory and Practice
More Information
As you work your way through this book, always remember
to relate your own experiences in the workplace to
the topics you study. An appreciation of the practical
application and significance of health and safety will help
you understand the topics.
Keeping Yourself Up to Date
The field of health and safety is constantly evolving and, as
such, it will be necessary for you to keep up to date with
changing legislation and best practice.
RRC International publishes updates to all its course
materials via a quarterly e-newsletter (issued in February,
May, August and November), which alerts students to key
changes in legislation, best practice and other information
pertinent to current courses,
Please visit www.rrc.co.uk/news/newsletters.aspx to
access these updates.
NEBOSH International
Diploma in Occupational Health
and Safety
Unit IA: International Management of Health
and Safety
Element IA1
Principles of Health and Safety
Management
Element IA2
Loss Causation and Incident
Investigation
Element IA3
Measuring and Reviewing Health and
Safety Performance
Element IA4
Identifying Hazards, Assessing and
Evaluating Risks
Element IA5
Risk Control
Element IA6
Organisational Factors
Element IA7
Human Factors
Element IA8
Regulating Health and Safety
Revision and Examination
User Guide
Before you start to use this textbook, take a moment to read this User Guide.
At the start of each element you will find a Contents table and a list of Learning Outcomes. These are important because
they give you an idea of the different topics you will be studying and what you are aiming to achieve.
KEY INFORMATION
Each main section of material starts with a Key Information box. This box presents an overview of the important
facts, ideas and principles dealt with under the section heading. There is no depth or detail here, just the basics.
After the Key Information box comes the main content. The main content has been designed to explain and describe the
topics specified in the relevant section of the syllabus to the expected level. Examples have been given to illustrate various
ideas and principles in a variety of different workplaces.
TOPIC FOCUS
MORE…
Topic Focus boxes provide depth and detail by
concentrating on a very specific topic area.
More... boxes contain sources of further information.
(Websites are current at the time of writing.)
Although this book includes everything you need,
it is worth looking at these additional sources if
you can. This will give you a broader and deeper
understanding.
GLOSSARY
Glossary boxes contain descriptions or definitions
of words or phrases that are included in the main
content.
HINTS AND TIPS
Hints and Tips boxes contain simple ideas that can
help you as you work through the materials and
prepare for the end-of-course exam.
REVISION QUESTIONS
At the end of each section you will find Revision
Questions. These are not past exam questions, but
should be useful for self-assessment.
You can mark your answers against the Suggested
Answers provided.
SUMMARY
Each element finishes with a Summary. This presents a very concise reflection of the key ideas and principles
contained in the element. When you have finished studying an element you might use the summary to test your
recall of the detailed information contained within the element.
When you have studied all of the elements in a unit you should move on to look at the Revision and Examination
Guide.
EXAM SKILLS
After each element you will find a short Exam Skills section containing an exam-style question (or two) for
you to practise answering. Guidance on how to answer is provided, together with a Suggested Answer for you to
compare with your own.
v2.1
PRINCIPLES OF HEALTH AND SAFETY
MANAGEMENT
ELEMENT
1
LEARNING OUTCOMES
On completion of this element, you should
be able to demonstrate understanding
of the content through the application
of knowledge to familiar and unfamiliar
situations and the critical analysis and
evaluation of information presented in
both quantitative and qualitative forms. In
particular you should be able to:

Explain
the moral, legal and economic reasons for a
health and safety management system.
the societal factors which influence health
Outline
and safety standards and priorities.

Explain
the principles and content of effective health
and safety, quality, environmental, and integrated
management systems with reference to recognised
models and standards.
the role and responsibilities of the health and
Outline
safety practitioner.
© RRC International
Unit IA – Element IA1: Principles of Health and Safety Management
v2.1
| 1-1
Contents
REASONS FOR MANAGING HEALTH AND SAFETY
Moral
Legal
Economic
Revision Question
1-3
1-3
1-3
1-4
1-4
SOCIETAL FACTORS WHICH INFLUENCE HEALTH AND SAFETY STANDARDS AND PRIORITIES
Significant Factors
Principle of Corporate Social Responsibility
Revision Question
1-5
1-5
1-6
1-6
INTRODUCTION TO MANAGEMENT SYSTEMS
Definitions
Key Elements of an Effective Health and Safety Management System
Principles and Benefits of Risk Management on a Global Perspective
Organisational Models for Health and Safety Management
Benefits and Limitations of Integrated Management Systems
Key Typical Components of OHS Management Systems
Quality and Environmental Management Systems
Arguments For and Against Integration of Management Systems
Reasons for the Introduction of Formal Health and Safety Management Systems
Role of the Health and Safety Policy
Requirements for a Written Health and Safety Policy and for Recording Arrangements
General Principles and Objectives of a Health and Safety Policy Document
Common Health and Safety Management Systems in Global Organisations
Influence of Corporate Responsibility and Business Ethics
Role of Health and Safety in Global Corporate Social Responsibility (CSR) Guidelines and Standards
Revision Questions
1-8
1-8
1-8
1-8
1-9
1-12
1-13
1-14
1-16
1-16
1-17
1-18
1-18
1-18
1-19
1-19
1-21
ROLE AND RESPONSIBILITIES OF THE HEALTH AND SAFETY PRACTITIONER
Influence on Health and Safety Management Systems
Health and Safety Involvement and Conduct
Competence and the Requirements for Continuing Professional Development
Responsibility to Evaluate and Develop Their Own Practice
Ethics and the Application of Ethical Principles
Dealing with Conflicts of Interest
Revision Questions
1-22
1-22
1-23
1-23
1-23
1-24
1-25
1-25
SUMMARY
1-26
EXAM SKILLS
1-28
1-2
| Unit IA – Element IA1: Principles of Health and Safety Management
© RRC International
v2.1
Reasons for Managing Health and Safety
KEY INFORMATION
• There are three fundamental reasons for organisations to manage health and safety risk:
• Moral – as human beings we should feel obliged to look after each other’s safety.
• Legal – there are strict legal obligations imposed on employers and employees relating to the safety of employees
and others affected by the business.
• Economic – businesses that address health and safety risk are invariably more successful than those that do not.
Loss events such as accidents or ill health lead to significant direct and indirect costs.
MORAL
It is widely accepted that moral reasons should be the
prime motivator for managing risk, although whether this
is actually the case is open to debate in some cases.
There is a need to maintain a moral code within our
society. Without it, employers may be tempted to treat
the health and safety of the workforce as being of less
importance than financial profit.
Moral reasons are based on the concept of an employer
owing a duty of reasonable care to his employees. A
person does not expect to risk life and limb, or physical
health, as a condition of employment.
Society expects every employer to demonstrate a correct
attitude to health and safety to his workforce. It is
unacceptable to place employees in situations where their
health and safety is at risk. Statistics relating to accidents/
incidents and ill health help to reinforce the message that
health and safety should be effectively managed. These
statistics also demonstrate that, proportionately, those who
work for small businesses are at significantly greater risk
than those who work for large organisations. This is clearly
morally wrong.
Over the years many moral obligations have been turned
into health and safety law. For example, the International
Labour Organisation’s (ILO) Occupational Safety and
Health Convention 1981, C155, identifies some basic
general legal duties of employers towards their employees
in Article 16:
“1. Employers shall be required to ensure that, so far as
is reasonably practicable, the workplaces, machinery,
equipment and processes under their control are safe
and without risk to health.
2. Employers shall be required to ensure that, so far as
is reasonably practicable, the chemical, physical and
biological substances and agents under their control
are without risk to health when the appropriate
measures of protection are taken.
3. Employers shall be required to provide, where
necessary, adequate protective clothing and protective
equipment to prevent, so far as is reasonably
practicable, risk of accidents or of adverse effects on
health.”
Copyright © International Labour Organisation 1981
In addition to the obvious duties owed by an employer to
his workers, he also has a moral obligation to protect other
people whose health and safety may be affected by his
undertaking, e.g. contractors or members of the public.
There are strong legal reasons for employers to manage
risk:
LEGAL
• Punitive - where the criminal courts impose fines
and imprisonment for breaches of legal duties. These
punishments can be given to the company, or to
individuals within the company.
In an ideal world organisations would all “self regulate” or
“self police”, so that organisations identified and enforced
the most appropriate health and safety standards for their
activities. This has several advantages, two of which are
that each business is in the best position to regulate its
own activities and it would also avoid the need to have
a separate (and costly) regulator. Unfortunately not all
organisations are sufficiently motivated or enlightened.
© RRC International
• Preventive - enforcement notices (improvement or
prohibition) can be issued by enforcement inspectors.
• Compensatory - where employees are able to sue in
the civil courts for compensation.
Unit IA – Element IA1: Principles of Health and Safety Management
v2.1
| 1-3
Reasons for Managing Health and Safety
ECONOMIC
Accidents and ill health are costly. These costs may be
calculable, arising directly from the accident, such as sick
pay, repairs to damaged equipment, fines and legal fees, or
more difficult to assign a monetary value to, such as lost
orders and business interruption. In practice, the costs that
are more difficult to calculate are often substantially more
than those that are easier to assess.
All employers are required to have certain types of
insurance against accidents, ill health, or other problems,
such as:
• Employers’ liability insurance.
• Public liability insurance.
• Motor vehicle insurance.
These insurances will cover some of the costs of accidents
and ill health, e.g. compensation claims from employees
and damage to motor vehicles. However, many of the
costs cannot be insured against, such as:
• Product and material damage.
Some of these costs are of indeterminate value. This
underlines the difficulty an organisation may have in
attempting to find out the true cost of accidents to the
business. The company may not have enough people
with the correct level of expertise and time to perform
the analysis. They may not even appreciate that some
costs exist and so miss them entirely. The culture of the
organisation might mean that many incidents are never
reported and so never find their way into statistics used
as a basis for costing. Some costs may not be known
accurately for a long time, e.g. where a civil case is ongoing and there may be a substantial compensation award.
Obtaining realistic cost estimates of the impact of more
subtle items, such as loss of morale (leading to lower
productivity) and loss of goodwill/public image (resulting
in lower sales), may be next to impossible.
There are clearly financial benefits to be gained from
positive health and safety management. Employers with
good health and safety management systems in place are
likely to save substantial sums on the costs of accidents
that would otherwise have happened.
• Lost production time.
• Legal costs in defending civil claims, prosecutions or
enforcement action.
• Overtime and other temporary labour costs to replace
the injured worker.
• Time spent investigating the accident and other
administration costs (including supervisor’s time).
• Fines from criminal prosecutions.
• Loss of highly trained and/or experienced staff.
• Effects on employee morale and the resulting
reduction in productivity.
• Bad publicity leading to loss of contracts and/or orders.
In a study by the UK’s Health and Safety Executive it
was shown that uninsured (hidden) costs can be 8 to 36
times the known insured costs. This was illustrated as an
“iceberg” model – where much of the costs (the uninsured
ones) lay hidden beneath the water.
REVISION QUESTION
1. Identify five costs of accidents that insurance will
not cover.
(Suggested Answer is at the end.)
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Societal Factors Which Influence Health and Safety Standards
and Priorities
KEY INFORMATION
• Economic climate - wealthy countries can afford to give occupational health and safety a higher priority than the
developing nations.
• Government policy - those who work tend to be healthier than those who are unemployed; improving workers’
health will help keep people at work, and they can then contribute financially to society.
• Risk profile - higher risk activities demand greater standards than those for lower risk activities.
• Globalisation - businesses that operate across the world may adopt different standards depending on the
requirements of the host countries.
• Migrant workers - in recent years immigration policies have increased the proportion of migrant workers.
• Societal expectations of equality - health and safety standards and priorities may include the requirement to make
adjustments to the workplace to accommodate workers with disabilities.
• Corporate social responsibility - the voluntary actions that businesses undertake to address not only their own
needs but also those of the wider society.
Level of Sickness Absence
SIGNIFICANT FACTORS
Economic Climate
The wealthiest countries of the world, where individuals
have access to the basic necessities for life such as food,
clean water and shelter, have the funding to create and
enforce good Occupational Health and Safety (OHS)
standards. In countries where individuals do not have these
resources, it is inevitable that OHS is given a relatively
lower priority.
Government Policy and Initiatives
The government has a major influence on OHS policy
through its ability to create legislation. In 2008 the UK
government published a document entitled Working for a
Healthier Tomorrow which made the following points:
• Life expectancy in the UK is higher than ever, yet
millions of working days are lost to work-related illness.
• Evidence suggests that the working population is
healthier than those who do not work. Families without
a working member are likely to suffer persistent low
income and poverty.
• Improving the health of the working age population
is critically important for everyone to secure higher
economic growth and its associated benefits.
© RRC International
In the UK, sickness absence has gradually reduced, but
is still substantial, with around 150 million days lost to
sickness absence each year. Incapacity benefits (being
replaced by Employment and Support Allowance) are paid
to those who are unable to work because of ill health or
disability.
Societal Expectations of Equality
Health and safety standards and priorities can be
determined by changes in societies’ expectations of
equality.
In the UK the Equality Act 2010 aims to protect disabled
people and prevent disability discrimination. The Equality
Act provides legal rights for disabled people in the area
of employment, requiring employers to make reasonable
adjustments to the workplace to accommodate workers
with disabilities. Consequently, acceptable access and
egress to a workplace may need to include provision of
ramps and lifts in order to comply with these expectations
of equality and the legal obligations associated with them.
Industry/Business Risk Profile
Not surprisingly, higher risk work activities require higher
standards of control than those that create lower risks. For
example, nuclear power stations each operate under a site
licence and demand very rigorous OHS standards.
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Societal Factors Which Influence Health and Safety Standards
and Priorities
Globalisation of Business
Many businesses of all sizes operate both nationally and
internationally, and so resolving differences in culture and
communication may create different expectations and
standards.
Migrant Workers
As a result of more flexible immigration policies, the
proportion of migrant workers in workforces is generally
increasing and cultural and communication issues may
influence OHS standards.
PRINCIPLE OF CORPORATE SOCIAL
RESPONSIBILITY
Corporate social responsibility is the term used to
describe the voluntary actions that a business can
take, over and above compliance with minimum legal
requirements, to address both its own competitive
interests and the interests of the wider society. Businesses
should take account of their economic, social and
environmental impacts, and act to address the key
sustainable development challenges based on their core
competencies wherever they operate – locally, regionally
and internationally.
REVISION QUESTION
2. Explain what is meant by the term ‘corporate
social responsibility’.
(Suggested Answer is at the end.)
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Introduction to Management Systems
KEY INFORMATION
• Risk management is useful to organisations and enables them to consider potential business impacts of
foreseeable events, formulate and carry out risk elimination/control, improve corporate governance, achieve
business objectives in a more targeted/efficient way, and retain/improve shareholder confidence.
• Most organisations have management systems for one or more aspects of management and two important
models are:
–– ILO-OSH-2001 Guidelines on Occupational Health and Safety Management Systems (ILO, 2001).
–– OHSAS 18001 Occupational Health and Management Systems: Specification (British Standards Institution,
2007).
• The key components in an effective health and safety management system are:
–– Management commitment.
–– Policy.
–– Organising.
–– Planning and implementing.
–– Performance review.
–– Audit.
–– Continual improvement.
• Total quality management and environmental management systems are detailed in:
–– ISO 9000 series.
–– ISO 14000 series.
• For organisations wishing to have control over safety, environment and quality, it may be possible to implement
an integrated management system (IMS) rather than individual systems, but there are arguments for and against
integration.
• The management system models offer a framework against which to allocate resources and responsibilities, set
and monitor performance standards and establish systems for feedback and implementation of corrective action
in order to minimise loss.
• The health and safety policy sets the whole framework of the safety management system and is an important
vehicle for the communication of health and safety information.
• A health and safety policy may be a requirement of national legislation in some regions.
• The health and safety policy usually comprises a statement of intent, an organisational structure and the
systems and procedures in place to manage risks and should include objectives that will contribute to business
performance.
• The introduction of common health and safety management principles, standards and systems in organisations
operating on a worldwide basis has both benefits and limitations.
• Corporate responsibility, where businesses take account of their social, economic and environmental impacts, and
business ethics should have a positive effect on health and safety management.
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Introduction to Management Systems
DEFINITIONS
Hazard
KEY ELEMENTS OF AN EFFECTIVE HEALTH
AND SAFETY MANAGEMENT SYSTEM
A hazard is something (an object or situation) with the
potential to cause harm.
TOPIC FOCUS
It can sometimes be helpful to categorise hazards into
types such as:
All management systems, whether they are designed
to manage health and safety or any other function,
have the same common elements:
• Physical, e.g. rotating blade of a circular saw.
• Chemical, e.g. strong acids and alkalis.
• Biological, e.g. contagious disease.
• Psychosocial, e.g. excessive workload.
• Plan - implies having a considered policy.
• Do - concerns the arrangements for putting the
plan into practice.
• Check - means it is necessary to assess or
monitor performance.
• Act - means performance should be reviewed
leading to continuous improvement in the
management system.
Notice how each of these elements is described in
the models we now look at.
PRINCIPLES AND BENEFITS OF RISK
MANAGEMENT ON A GLOBAL PERSPECTIVE
Risk
Risk is the likelihood that a specified harm from a
particular hazard is realised.
Risk is a computation of the likelihood of harm being
done and the severity of that harm. The term ‘risk’
carries the idea of ‘chance taking’. Risk may be taken after
careful consideration of the consequences or just out of
ignorance. The result of risk-taking can be fortunate or
disastrous, or anything in between.
“Risk management” has been defined as: “the culture,
processes and structures that are directed towards realising
potential opportunities whilst managing adverse effects”
(from the AS/NZ 4360 Risk Management Standard).
Everything we do in life involves some element of risk.
Good businesses take calculated risks all the time. They
seek to maximise their opportunities and minimise the
adverse effects.
The following figure shows the place of health and
safety risks in business (based on an IOSH publication on
Business Risk Management).
Danger
Danger is a liability or exposure to harm; a thing that
causes peril.
The term ‘danger’ is a general word, but carries the idea of
harm to a person.
Health and Safety Risks in Business
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Health and safety management should not be seen as
something separate from business. For example, poor
health and safety management can have a severe impact
on brand/image/reputation, insurance premiums, etc.
Health and safety is largely concerned with pure risks
(i.e. where there is only loss – such as disease, damage,
injury).
Loss control is also concerned with pure risks, but is
wider in scope, additionally encompassing fire, security,
environment and business recovery considerations.
Risk management is wider still and is concerned with
speculative risks (i.e. where there could be loss or gain).
It involves additional consideration of finance, insurance,
brand/reputation, business continuity, etc.
Corporate governance is even wider and is concerned
with holistic risk (i.e. looking at risks as a whole, taking
account of the interaction/impact of different risks
on the business). It adds to risk management by using
management systems, and incorporates such things
as Corporate Social Responsibility (CSR) and Socially
Responsible Investing (SRI).
ORGANISATIONAL MODELS FOR HEALTH
AND SAFETY MANAGEMENT
Most organisations have management systems for one or
more aspects of management. Two models are outlined
below.
OHSAS 18001 Occupational Health
and Safety Management Systems:
Requirements. British Standards
Institution, 2007
OHSAS 18001 is a certifiable health and safety
management system standard that was introduced in 1999
and revised in 2007. Its purpose is to help organisations
create management systems that their stakeholders can
see have required characteristics. Although published in
the UK by BSI, OHSAS 18001 was also subject to separate
international negotiation and agreement. Compliance with
certifiable standards is demonstrated through audit by a
certifying body, which itself should be accredited by the UK
Accreditation Service (UKAS).
Risk management involves the following distinct activities:
• Risk identification: by using inspections/checklists, task
analysis, SWOT (strengths, weaknesses, opportunities,
threats), etc.
• Risk evaluation: based on economic, social, legal
considerations with data on frequency of occurrence,
severity of business consequences, etc.
• Risk elimination and control: avoidance, transfer,
retention, reduction.
GLOSSARY
CERTIFICATION
The process by which a company wishing to move
to, say, a safety management system based on
OHSAS 18001 gets certified, registered or approved
to that standard.
CERTIFICATION BODY
An organisation such as BSI or LRQA (Lloyd’s
Register Quality Assurance) which carries out the
certification process.
• Monitoring.
• Audit.
• Review.
ACCREDITATION
Monitoring/audit and review are common to many
management models.
Risk management is useful to organisations. Amongst
other things, it enables them to:
• Look at potential business impacts of foreseeable
events.
• Respond to changes in risk perception.
• Formulate and carry out risk elimination/control.
The process by which certification bodies have
their processes assessed to see if they meet the
Regulatory Authority’s (or Accreditation Body’s)
standards (in the UK, this is the United Kingdom
Accreditation Service (UKAS)).
So, an individual organisation gets certification to a
standard like OHSAS 18001; the certifying body that
awards that standard (e.g. LRQA) can do so because
it has accreditation from UKAS.
• Improve corporate governance (by incorporating risk
elimination/control strategies into the organisation’s
general processes).
• Achieve business objectives in a more targeted/
efficient way, e.g. working towards regulatory
compliance.
• Retain/improve shareholder confidence.
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Introduction to Management Systems
The following figure is based on that included in the
OHSAS 18001 standard.
Planning
This is needed for the effective identification of hazards
and assessment and control of risks. This means that
the organisation needs procedures to cover risks in all
activities, and for identifying any applicable law. The
organisation should establish health and safety objectives
consistent with the health and safety policy and establish a
management programme to achieve those objectives. The
management programme will include designation of roles/
responsibilities, timescales, etc.
Implementation and Operation
Occupational Health and Safety Assessment Series 18001 (OHSAS
18001): health and safety management model
The necessary organisational structure and resources need
to be put in place to implement the plans, though top
management retain ultimate responsibility. People should
be competent to perform their designated roles, and
this may involve training and maintaining awareness. The
organisation requires systems in place to make sure that
health and safety information is communicated to/from
employees. Employees should also be consulted on health
and safety matters and be involved in the development
and review of policies and procedures.
This model is based on ISO 14001 and HSG65 (a health
and safety management system favoured by the UK HSE)
and requires an organisation to determine its existing
health and safety activities, and to develop programmes
and systems that focus on the elimination of risk to staff
and other parties. These processes are then developed
into a management system that aims to ensure that health
and safety performance is continuously monitored and
improved.
It is important to document the systems and exercise
control over those documents (so that they are accessible,
periodically reviewed, kept up to date (version control),
retained (e.g. legal requirements for document retention)).
There should be documented procedures where necessary
to control risks arising from the range of operations within
the organisation. In particular, there should be plans and
procedures (which should be regularly tested) to cover
potential emergencies.
Companies cannot simply claim that they have a standard
that meets the requirements of OHSAS 18001 – they
have to go through a certification process, overseen by
an independent external certification body such as BSI or
LRQA, which sends an auditor to verify that the company’s
system meets the OHSAS 18001 standard. This is a major
difference when compared with ILO-OSH-2001 (see
below), which does not require such external certification.
OH and S Policy
This should state the overall health and safety objectives
of the organisation and express commitment to improving
health and safety performance. To demonstrate that
commitment, the policy should be authorised by top
management. The policy should commit the organisation
to continual improvement and compliance with legislation.
It should be communicated to all employees and other
interested parties and kept up to date by periodic review. It
should also be documented.
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Checking and Corrective Action
The organisation needs procedures to ensure that it
regularly measures and monitors health and safety
performance (proactive, reactive, qualitative, quantitative).
Procedures should also be in place to record and
investigate accidents/non-conformances and to make
sure that remedial actions are implemented and that such
actions have been effective. Occupational health and
safety data (including audit and review results) should be
recorded. There should be an audit programme to identify
whether the occupational health and safety management
system is operating as planned and is effective.
Company employees can conduct audits. These are known
as internal audits and are a method of self-regulation,
which enable the company to assess its own performance
against the standard. External audits are conducted by
people from outside the company and give a valuable
third-party viewpoint, which many people see as being
more impartial. The certification body will be one such
external organisation and will conduct audits when
certification to a particular standard is about to expire.
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Management Review
Organising
This is the job of top management. The whole system
should be periodically reviewed to make sure it continues
to be effective. This relies on results gathered during
the “checking and corrective action” stage. The review
may, in turn, lead to changes in the policy, objectives and
other elements of the management system. It should, like
everything else, be documented.
Whilst the employer retains overall responsibility for health
and safety, specific roles should be delegated/allocated
throughout the organisation, including delegation of
responsibility, accountability and authority. The structure
and processes need to be in place to, amongst other
things:
ILO-OSH-2001 Guidelines on
Occupational Health and Safety
Management Systems. ILO, 2001
• Actively promote co-operation and effective two-way
communication in order to implement the safety
management system.
• Establish arrangements to identify and control
workplace risks.
The figure below illustrates the elements of this system
and is reproduced by kind permission of the International
Labour Organisation (ILO). Note that the basic elements
are very similar to OHSAS 18001 in concept. It is intended
that the safety management system should be compatible
with, or integrated into, other management systems within
the organisation.
• Provide supervision.
• Provide adequate resources, etc.
Particularly recommended is the appointment of a senior
individual to oversee the development and maintenance
of the occupational health and safety management system
elements as a whole, promoting participation and periodic
performance reporting.
Competence and training are stressed as key elements
needed to implement such a programme. Occupational
health and safety management system documentation
(policy, objectives, key roles/responsibilities, significant
hazards and methods of prevention/control, procedures,
etc.) should be created and maintained. Additionally,
records should be kept, e.g. accident data, health
surveillance and other monitoring data.
Planning and Implementation
This should start with an initial review to understand
the organisation’s current position. It should: identify
applicable laws, standards, guidelines; assess health and
safety risks to the organisation; determine if existing (or
planned) controls are adequate; analyse health surveillance
data, etc. This initial review provides the baseline for future
continuous improvement.
Model Health and Safety Management System (ILO-OSH-2001)
Copyright © International Labour Organisation 2001
Policy
Developed in consultation with workers, this should
be signed by a senior member of the organisation. It
should commit the organisation to protecting the health
and safety of employees, compliance with applicable
laws and guidance, consultation with employees and
their participation, and continuous improvement. The
guidance stresses forcefully the importance of employee
consultation and participation in all elements of the safety
management system for it to be effective. As such the ILOOSH guidelines strongly recommend the establishment
of a health and safety committee and the recognition of
safety representatives.
© RRC International
The next stage is the planning, development and
implementation of the safety management system (based
on the results of initial or subsequent reviews). This should
involve the setting of realistic, achievable objectives and
the creation of a plan to meet those objectives, as well as
selecting appropriate measurement criteria which will later
be used to see if the objectives have been met and for the
allocation of resources.
Preventive and protective measures should be planned and
implemented to eliminate and/or control risks to health
and safety. These should follow the general hierarchy of
control: eliminate; control at source (using engineering and
organisational measures); minimise (safe systems of work,
including administrative controls); and PPE if risks cannot
be adequately controlled by collective measures.
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Introduction to Management Systems
Management of change is also important. Changes may
occur internally (new processes, staff, etc.), as well as
externally (legal changes, mergers, etc.), and it is important
to manage those changes in a systematic way. Risk
assessment is a key part of that, as well as ensuring that
people are consulted and that any proposed changes are
properly communicated to those likely to be affected.
Plans should also cover foreseeable emergencies
(prevention, preparedness and response aspects), such as
fire and first aid.
Procurement procedures should make sure that health and
safety requirements (national and organisational) are an
integral part of purchasing and leasing specifications.
You should also ensure that the organisation’s health and
safety requirements are applied to contractors (including
contractor selection and their work on site (hazard
awareness, training, co-ordination and communication,
accident reporting, site rules, compliance monitoring,
etc.)).
Evaluation
Procedures need to be in place to monitor, measure and
record the performance of the health and safety system.
You should use a mixture of qualitative and quantitative
and active and reactive performance measures, and not
just rely on accident rate data! Active monitoring includes
things such as inspections, surveillance, compliance with
laws, achievement of plans, etc. Reactive monitoring
includes reporting and investigation of accidents/
ill-health and occupational health and safety system
failures. Accidents, etc. should be properly investigated
to determine the root cause failures in the system.
Investigations should be properly documented and
remedial action implemented to prevent recurrence.
The organisation should have an audit policy (scope,
competency, frequency, methodology, etc.). Audits seek
to evaluate the performance of the occupational health
and safety management system elements (or a sub-set)
and should at least cover: policy; worker participation;
responsibility/accountability; competence and training;
documentation; communication; planning, development,
implementation; preventive and control measures;
management of change; emergency preparedness;
procurement; contracting; performance monitoring/
measurement; accident investigations; audits; management
review; preventive and corrective action; and continuous
improvement.
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Like audits conducted under OHSAS 18001, audits under
ILO-OSH-2001 can be internal or external although, unlike
OHSAS 18001, external audits are not mandatory. In the
case of ILO-OSH-2001, external audits are not conducted
by a certification body, since there is no certification
requirement. Instead, if the company wants one,
independent auditors who are specifically commissioned
for the task can carry them out. The audit should
ultimately make conclusions about the effectiveness of the
occupational health and safety management system.
A management review should evaluate the overall
occupational health and safety management system
and progress towards the organisation’s goals. It will use
data from monitoring, measuring and auditing of the
system as well as take account of other factors (including
organisational changes) that may influence the system
in the future. It will establish if changes are needed to
the system (or components of it). The results need to be
recorded and communicated.
Action for Improvement
Occupational health and safety management system
performance monitoring, audits and management reviews
will necessarily create a list of corrective actions. You must
ensure that, firstly you establish the root causes of the
problems requiring correction, and secondly, there is a
system in place for making sure that actions are carried out
(and checks made on their effectiveness).
Continual Improvement
The organisation should strive to continually improve. It
should compare itself with other similar organisations.
BENEFITS AND LIMITATIONS OF
INTEGRATED MANAGEMENT SYSTEMS
For organisations wishing to have control over more than
one aspect of risk management, e.g. safety, environment
and quality, it may be possible to implement an Integrated
Management System (IMS) rather than individual systems.
Though it may make sense in theory, implementing an IMS
is not an easy task, and there are a variety of factors to be
taken into account.
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Introduction to Management Systems
TOPIC FOCUS
Arguments for integration:
• A well-planned IMS is likely to operate more cost-effectively than separate systems, and facilitate decision-making
that best reflects the overall needs of the organisation.
• An IMS offers the prospect of more rewarding career opportunities for specialists in each discipline.
• The objectives and processes of management systems are essentially the same.
• Integration should lead to the avoidance of duplication, e.g. in personnel, meetings, electronic record-keeping,
software, audits and paperwork.
• Integration should reduce the possibility of resolving problems in one area at the expense of creating new
difficulties in other disciplines.
• An IMS should involve timely overall system reviews where momentum in one element of an IMS may drive
forward other elements that might otherwise stagnate. In contrast, independent systems could develop without
regard to other management system elements, leading to increased incompatibility.
• A positive culture in one discipline may be carried over to others.
Arguments against integration:
• Existing systems may work well already. Integration may threaten the coherence and consistency of current
arrangements that have the support of everyone involved.
• Relevant specialists may continue to concentrate on the area of their core expertise and further specialist training
may not be needed.
• Uncertainties regarding key terms – already a problem in health and safety – would be exacerbated in an IMS.
• System requirements may vary across topics covered, e.g. an organisation may require a simple quality system, but
a more complex health and safety or environmental performance system. An IMS could introduce unreasonable
bureaucracy into, in this case, quality management.
• Health, safety and environmental performance are underpinned by legislation and standards, but quality
management system requirements are largely determined by customer specification.
• Regulators and single-topic auditors may have difficulty evaluating their part of the IMS when it is interwoven
with other parts of no concern to the evaluator.
• A powerful, integrated team may reduce the ownership of the topics by line management.
• A negative culture in one topic may unwittingly be carried over to others.
Planning and Implementing
KEY TYPICAL COMPONENTS OF OHS
MANAGEMENT SYSTEMS
For OHSAS, “Planning” is broken out as a separate step,
but “Implementing” is covered under “Implementation
and Operation”.
Management Commitment
Without commitment from the top, the management
system will not be effective. This is usually described in
sections on “Policy” and “Organising” in management
system models.
Policy
Performance Review
ILO-OSH covers this under “Evaluation”. OHSAS covers
this under “Checking and Corrective Action” and
“Management Review”.
This is the same for OHSAS 18001 and ILO-OSH.
Audit
Organising
This is part of ILO-OSH and OHSAS and is usually
discussed in the section on reviewing/evaluating
performance of the system as a whole.
For OHSAS this is part of the “Implementation and
Operation” step.
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Introduction to Management Systems
Continual Improvement
The processes involved in effective health and safety
management systems should lead to the continuous
monitoring and improvement of health and safety
performance.
QUALITY AND ENVIRONMENTAL
MANAGEMENT SYSTEMS
BS EN ISO 9001:2008 - Quality
Management Systems
ISO 9001 specifies requirements for a quality management
system where an organisation has to demonstrate its ability
to consistently provide a product or service that meets
customer and applicable regulatory requirements. Just like
OHSAS 18001, organisations can be audited against this
standard and their compliance certified accordingly.
ISO 9001 is part of a family of standards in the same series.
In particular it is based upon, and needs to be understood
in the context of, the eight quality principles outlined in
ISO 9000 and ISO 9004:
1. Customer Focus – understand customer needs (current
and future), meet customer requirements, exceed
customer expectations (customer satisfaction).
2. Leadership – create and maintain internal environment
which encourages involvement.
3. Involvement of people – full involvement/
contributions by everyone.
4. Process approach – it is more efficient to manage
activities and resources as a process (inputs-processoutputs). Processes should at least cover the
following areas: management responsibility, resource
management, product realisation, measurement,
analysis and improvement.
5. Systems approach to management – it is more effective
and efficient to manage interrelated processes as a
system.
6. Continual Improvement – of the overall performance
should be a permanent objective.
7. Factual approach to decision-making – decisions are
more effective if based on analysis of data/information.
8. Mutually beneficial supplier relationships – the
interdependency of client and supplier.
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The standard consists of five main clauses which are interrelated:
• Quality Management System (QMS)
Establish, document, implement, maintain and
continually improve a QMS. Have in place the relevant
documentation (quality policy, objectives, manual,
procedures, records) and processes to control those
documents and records (i.e. version control).
• Management Responsibility
This covers: commitment, customer focus,
quality policy, planning, responsibility, authority,
communication, and management Review.
• Resource Management
Provision of: resources, competence/training/
awareness, infrastructure, work environment.
• Product Realisation
This is everything from inception to delivery of the
product, so covers: planning of processes, customer/
product requirements, customer communication,
design/development, purchasing, production/service
provision, monitoring/measuring equipment.
• Measurement, Analysis and Improvement
Customer satisfaction, internal auditing, monitoring
and measurement of processes and product, control
of non-conforming product, analysis of data,
improvement (continual improvement, corrective
actions, preventive action).
ISO 9001 promotes the adoption of a process approach
that may be used to identify and manage numerous linked
activities.
GLOSSARY
PROCESS APPROACH
This is where individual activities and their related
resources are identified and managed as a process
(each with their inputs and outputs). An organisation
can be viewed as a system comprising a network of
these interrelated processes (where outputs of one
process can be the inputs for others).
An advantage of the process approach is the on-going
control it provides over the linkage between the
individual processes, as well as over their combination and
interaction. You can see the process approach outlined in
the following:
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Model of a process-based quality management system
This model shows that customers play a major role in
defining requirements as inputs and the monitoring
of customers’ satisfaction requires the evaluation of
information relating to customer perception.
One major insurance company has made the point that
ISO 9001 is a good way of involving top management in
safety matters. Senior management usually complain
that safety is beyond their sphere of experience, yet they
are familiar with the approach of ISO 9001 from a quality
control viewpoint. Therefore, if the provision of a “safe
system of work” is discussed from the ISO 9001 stance,
senior managers are already familiar with the terminology
adopted and are more likely to become involved. In this
way, safety is integrated into the total performance of the
company and not treated as a separate issue.
BS EN ISO 14001: 2004 – Environmental
Management Systems – Requirements
with Guidance for Use
BS EN ISO 14001 is a stand-alone, auditable environmental
management system standard for certification. Study the
next figure carefully. The steps represent the stages in the
process. Once again, a general management framework
approach is applied, and there are clear similarities with
ISO 9001 and OHSAS 18001 (the latter in part being based
on ISO 14001 in any case).
The similarity and compatibility of the safety management
systems and the quality management systems mean that
management committed to quality systems have few
problems in widening the scope to include safety and
health.
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Introduction to Management Systems
ARGUMENTS FOR AND AGAINST
INTEGRATION OF MANAGEMENT SYSTEMS
We discussed these earlier when we considered
the benefits and limitations of integrated quality,
environmental, and health and safety management
systems.
REASONS FOR THE INTRODUCTION
OF FORMAL HEALTH AND SAFETY
MANAGEMENT SYSTEMS
The management system models we have discussed offer
a framework for management to focus on in order to
manage health and safety – policy, organising, planning
and implementing, measuring performance, reviewing
performance, auditing the system.
Management involves:
The ISO 14001 model
1. Environmental Policy
This obviously needs very careful consideration. Set
the policy and have effective means of measuring the
performance.
2. Planning
Detailed consideration of how the policy is to be
carried out. The planning must include forward
planning, and plans for continual improvement.
3. Implementation and Operation
A vital point in implementation is the total
commitment of all managers to the full
implementation of Total Quality Management.
4. Checking
As with all management systems there will need to be
periodic checks. These must be clearly spelt out, stating
what is checked, how, and who takes action.
5. Management Review
This is the main review of efficiency and effectiveness.
Management action and changes may need to be
implemented.
6. Continual Improvement
The circle has to be closed. If changes need to be made
then these will involve the policy, the planning and the
implementation stages
• Policy-making.
• Setting objectives and performance standards.
• Providing resources.
• Making judgments - considering alternatives.
• Coming to decisions.
• Taking action.
• Accountability.
• Monitoring and control.
Safety legislation places on management the major
responsibility for the health and safety of workers and
others on a company’s premises. While most of these
duties cannot be delegated, the day-to-day activities clearly
are.
In this section, we examine some practical management
issues in more detail.
Appropriate Allocation of Resources
The provision of both financial (for equipment, training,
consultancy, etc.) and manpower (enough and with the
right skills) resources is essential in the management
of health and safety. Risk assessment is a powerful tool
for identifying priorities for which resources need to
be allocated. However, management expects that the
benefits will outweigh the costs because accidents
and compensation for occupational illness can be very
expensive items. Costs of accident and ill health prevention
need to be carefully controlled and effective.
An important factor in this equation is that the costs of
accident prevention have a ‘lead time’. Money has to be
spent in advance of the benefits being felt. Safety training,
which is also a requirement of legislation, shows results
some time after the expenditure has been incurred.
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The safety practitioner needs to think very carefully about
ways of calculating the cost of accidents and ill-health, so
that there are definite figures available to demonstrate
the benefits of any accident reduction which has been
achieved. We look at cost/benefit analysis in a later
element.
Appropriate Allocation of Responsibilities
Responsibilities should be linked to specific outputs. Good
performance standards should identify:
• Who is responsible - either by name or position.
Those given responsibilities should be competent to
carry out the tasks.
• What they are responsible for - what needs to be
done and how it is to be done.
Part of management control is making sure that
responsibilities for specific tasks and roles are allocated to
individuals within the organisation.
• When the work should be done - is it a regular
occurrence, such as a monthly inspection, or irregular
and only when certain tasks are carried out?
Responsibilities must:
• What the expected result is - do any legal
requirements have to be satisfied, such as attaining a
certain level of noise? The result may, alternatively, be
the achievement of a specified organisational output,
such as training.
• Be clear (especially important when third parties
are involved) – people should know what they are
responsible for.
• Be allocated to individuals who have the necessary
competence.
• Be supported with necessary resources.
• Go hand in hand with accountability.
Everyone will have responsibility for health and safety
to some extent, but some will have specific additional
responsibilities, such as:
• Preparing plans to implement the health and safety
policy.
• Carrying out risk assessments in accordance with
specific regulations.
• Periodic monitoring of health and safety performance.
• Providing training.
• Checking contractors’ health and safety performance
before awarding contracts.
• Providing first aid after an accident.
To ensure that the standards are being achieved, it is
important to monitor them. This will allow shortcomings
to be identified and action taken to correct them.
Monitoring should be seen as an integral part of the
management system and not as ‘checking up’ on
individuals.
Feedback and Implementation of
Corrective Action
For any system to be effective, it is necessary to have a
complete loop that allows for action to be taken where
discrepancies are identified. By feeding back, to the
appropriate people within the organisation, information
obtained during monitoring and audit processes, suitable
corrective action can be implemented. Without this
important function, the whole management system will
fail to develop and become a paper exercise with no
discernible improvement in safety.
ROLE OF THE HEALTH AND SAFETY POLICY
Setting and Monitoring Performance
Standards
In order to determine how well an organisation is
performing in any function it is necessary to have
something to measure. It is important to ensure that
everybody knows what is expected of them in controlling
risks within the organisation. Performance standards
should ensure that the intentions of the safety policy are
transferred into action. Standards should be measurable,
achievable and realistic.
Standards should:
• Set out clearly what people need to do to contribute to
an environment which is free of injuries, ill health and
loss.
In Relation to a Health and Safety
Management System
The policy sets the whole framework of the Safety
Management System (SMS). From an SMS point of view,
the policy is just a statement of intent – a demonstration
of commitment. It frames the company vision on health
and safety. The policy should state the overall health
and safety objectives of the organisation and express
commitment to improving health and safety performance;
to demonstrate that commitment, it should be authorised
by top management. It should commit the organisation to
continual improvement and compliance with legislation,
and should be communicated to all employees and other
interested parties, and kept up to date by periodic review.
• Help identify the competencies which individuals need
to fulfil their responsibilities.
• Form the basis for measuring individual, group and
organisational performance.
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Introduction to Management Systems
As a Vehicle for the Communication of
Health and Safety Information
Effective health and safety policies contribute to business
performance by:
A health and safety policy:
• Supporting human resource development.
• Tells people about a company’s approach to managing
health and safety.
• Minimising the financial losses which arise from
avoidable unplanned events.
• Communicates the organisation’s commitment to
health and safety to existing employees (preferably by
means of their own copy).
• Recognising that accidents, ill health and incidents
result from failings in management control and are not
necessarily the fault of individual employees.
• Can be used:
• Recognising that the development of a culture
supportive of health and safety is necessary to achieve
adequate control over risks.
–– In the induction of new employees (to stress the
importance of safety).
–– To involve workforce representatives in writing and
amending the policy, when necessary.
–– At regular briefing sessions to communicate
information relating to different sections of the
policy.
REQUIREMENTS FOR A WRITTEN HEALTH
AND SAFETY POLICY AND FOR RECORDING
ARRANGEMENTS
A health and safety policy may be a requirement of
national legislation in some regions. Even if it is not a
legal requirement, it is required by ILO-OSH 2001 (which
supports ILO conventions) and OHSAS 18001.
The policy should be documented (paper or electronic)
and authorised by top management (e.g. chief executive
officer). The policy is meaningless on its own; it
needs to be implemented through “organisation” and
“arrangements” within a safety management system.
• Ensuring a systematic approach to the identification of
risks and the allocation of resources to control them.
• Supporting quality initiatives aimed at continuous
improvement.
COMMON HEALTH AND SAFETY
MANAGEMENT SYSTEMS IN GLOBAL
ORGANISATIONS
Simplistically, implementation steps must include:
• Choose a safety management system – what might
influence your choice?
• Initial status review (gap analysis).
• Make it happen – harder than it sounds!
The gap analysis will need a number of inputs, such as:
• Information relating to risk assessment.
• Review of occupational safety and health performance
(accident statistics, etc.).
GENERAL PRINCIPLES AND OBJECTIVES OF
A HEALTH AND SAFETY POLICY DOCUMENT
• Information on current occupational safety and health
management arrangements and procedures.
The health and safety policy is usually made up of:
• Competence and training needs.
• A statement of intent that sets out the aims and
objectives of the organisation regarding health and
safety.
• Worker participation.
• An organisational structure that details the people with
health and safety responsibilities and their duties.
• The systems and procedures in place to manage risks.
• Standards (legal, guidance on best practice, codes of
practice).
This is then used to formulate an occupational safety and
health management plan to cover:
• Policy.
• Risk assessment.
• Management arrangements for occupational safety and
health.
• Competence and training needs.
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Most safety management systems come with extensive
practical guidance in subsidiary documents, which tell you
how to get started and continue the process. It takes time,
resources and commitment to achieve the perfect system
and then implement it. Accept that your initial system will
not be perfect and use the in-built mechanisms of audit,
performance measurement, review, etc. to continually
improve the system. Fundamental to this process is the
safety culture within the organisation (see later elements).
Some of the drivers, benefits and limitations of
implementing common systems, principles and standards
within a global organisation include:
• A formal occupational health and safety management
system approach is increasingly favoured by regulators
throughout the world, and may be legally required in
some regions.
• Modern goal-setting legislation implies the need for an
occupational health and safety management system as
a form of “self-regulation”.
• Multi-national organisations favour a consistent,
standardised approach throughout the organisation
– just like the business management system
(“globalisation”).
• Possible cultural/social and legal barriers.
• Possible resistance to change (adequacy of existing
systems, bureaucracy, cost).
INFLUENCE OF CORPORATE RESPONSIBILITY
AND BUSINESS ETHICS
ROLE OF HEALTH AND SAFETY IN GLOBAL
CORPORATE SOCIAL RESPONSIBILITY (CSR)
GUIDELINES AND STANDARDS
UN Global Compact
The Global Compact is a CSR initiative. The ultimate
vision is a more sustainable and inclusive global economy.
The principles are based on a number of well known
agreements:
• Universal Declaration of Human Rights.
• International Labour Organisation’s Declaration on
Fundamental Principles and Rights at Work.
• The Rio Declaration on Environment and
Development.
• United Nations Convention Against Corruption.
The fundamental “ten universal principles” of the Global
Compact (subscription to which is voluntary) are described below (with some examples of possible health and
safety management system contributions).
Human Rights
Principle 1: Businesses should support and respect the
protection of internationally proclaimed human rights; and
(e.g. Health and safety management systems can help
ensure legal compliance and consistent application of
standards in different parts of the world (even where they
have lower national standards). Investing in a positive
health and safety culture can help retain staff, too.)
“Corporate responsibility” (also called corporate social
responsibility) is difficult to define and is used to cover
a wide range of issues. Essentially it is where businesses
take account of their social, economic and environmental
impacts (all of which can affect their reputation and
profitability). Some impacts of corporate responsibility on
safety management include:
Principle 2: make sure that they are not complicit in
human rights abuses.
• Greater board-level leadership (directors).
(e.g. Good health and safety management encourages
consultation and participation at every level.)
• Public reporting of health and safety performance
(annual reports to shareholders).
• Improved management control systems – (health
and safety risks seen within the overall business risk
management framework).
In practice it means a whole range of initiatives, because
it goes beyond mere basic compliance with legal
requirements and concentration on short-term costs/
benefits. Corporate responsibility invests in the long-term
benefits of more socially positive projects, e.g. work-life
balance. We will consider some of these issues again when
we look at organisational factors.
© RRC International
Labour Standards
Principle 3: Businesses should uphold the freedom of
association and the effective recognition of the right to
collective bargaining;
Principle 4: the elimination of all forms of forced and
compulsory labour;
Principle 5: the effective abolition of child labour; and
Principle 6: the elimination of discrimination in respect of
employment and occupation.
(e.g. This could potentially occur in an occupational health
and safety context – so the safety management system
should help ensure that selection of an individual for a task
is based on such things as suitability, competence and risk,
rather than gender, age or physical capability. The safety
management system should help adapt procedures, tasks
and equipment to the individual by making reasonable
adjustments.)
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Introduction to Management Systems
Environment
Principle 7: Businesses should support a precautionary
approach to environmental challenges;
Principle 8: undertake initiatives to promote greater
environmental responsibility; and
(e.g. Even without specific environmental management
systems, a safety management system will necessarily have
an impact on some environmental issues. For example,
the identification and prevention/control of potential
chemical spillage scenarios will have a positive benefit for
the environment.)
Principle 9: encourage the development and diffusion of
environmentally friendly technologies.
Anti-Corruption
Principle 10: Businesses should work against corruption in
all its forms, including extortion and bribery.
(e.g. A documented SMS should make the processes
transparent and some forms of corruption easier to
detect.)
The idea is that these principles should be embedded in all
the activities of a business so that the organisation behaves
with a social conscience. Businesses are encouraged to sign
up to the principles and report their progress annually in a
“Communication on Progress“ report. See if you can think
of how your organisation might implement these basic
principles in the health and safety context.
Social Accountability 8000
This is an auditable standard and shares a number of
principles with the UN Global Compact because it is based
on some similar global conventions. However, it is wider
in scope – it requires compliance with a wide range of ILO
conventions, as well as the Universal Declaration of Human
Rights and the UN Convention on the Rights of the Child.
The standard can be downloaded (in several different
languages) from www.sa-intl.org/.
Whilst the standard is freely available, specific
implementation guidance is not. The basic principles
include:
1. Child Labour: no use or support of child labour; remediation of children found to be working; support to
enable attendance at school; conditional employment
of young workers.
2. Forced or Compulsory Labour: no use or support of
forced labour or human trafficking; personnel free to
terminate employment.
3. Health and Safety: provide a safe and healthy workplace; prevent accidents; provide PPE; senior manager
responsible for OSH; establish a health and safety
committee; health and safety training for all workers;
system to detect and respond to health and safety risks;
1-20
accident records; access to toilets and potable water;
suitable areas for meal breaks; worker’s right to remove
himself from imminent danger; reduce risks to new and
expectant mothers.
4. Freedom of Association and Right to Collective
Bargaining: respect the right to form and join a trade
union; where law restricts these freedoms, allow freely
elected representatives; no discrimination on account
of participation in worker organisations.
5. Discrimination: no discrimination on account of race,
caste, origin, religion, disability, gender, sexual orientation, union or political affiliation, or age; no threatening
or abusive behaviour.
6. Disciplinary Practices: treat personnel with dignity and
respect; no corporal punishment, mental or physical
abuse.
7. Working Hours: comply with the law and industry
standards; no more than 48 hours per week; one day
off for every seven-day period; voluntary overtime not
exceeding 12 hours per week; overtime mandatory
only if part of a collective bargaining agreement.
8. Remuneration: right to living wage – at least legal
minimum; no disciplinary deductions; overtime paid at
premium rate.
9. Management System: to gain and maintain certification, organisations must go beyond simple compliance
and integrate the standard into their management
systems and practices.
SA8000:2014 is the recently revised version which makes
no substantive changes but clarifies the language used, is
more consistent throughout the elements and explicitly
addresses abusive practices that have become more
common since 2008.
Global Reporting Initiative (GRI)
The stated vision of the GRI is to make reporting on
economic, social and environmental performance as
routine as financial reporting. The GRI is therefore a
standard framework for reporting, and contains some
specific occupational health and safety Reporting
Performance Indicators (RPI).
The GRI reporting can be used to produce the UN Global
Compact’s annual “Communication on Progress” report.
Companies routinely report finances. Company finances
are, of course, part of economics but economics is wider
than that. In this context, we are interested in the impact
of the business on the wider economic system as a whole,
as well as social and environmental impacts/performance.
You can download a full copy of the reporting guidelines
from www.globalreporting.org.
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Health and safety has a clear role in supporting the GRI,
which in turn supports the Global Compact, and so
corporate social responsibility. In terms of health and
safety (which is considered part of the “social” reporting
category), there are some specific items of note for
disclosure in reporting:
• Management approach to occupational health and
safety.
• Goals and performance.
• Organisation responsibility (i.e. the organisational
roles/structure assigned to dealing with it).
• Training and awareness aspects.
• Monitoring and follow-up (corrective actions, etc.).
RPIs identified for disclosure on occupational health and
safety include:
MORE…
A full copy of the reporting guidelines can be
downloaded from:
http://www.globalreporting.org
The European Agency for Safety and Health at Work
guide, Management Leadership in Occupational
Safety and Health – a practical guide, gives business
leaders practical information on how safety and
health can be improved through effective leadership,
worker involvement and ongoing assessment and
review and is available at:
https://osha.europa.eu/en/publications/reports/
management-leadership-in-OSH_guide/view
• G4-LA5 - Percentage of total workforce represented
in formal joint management–worker health and
safety committees that help monitor and advise on
occupational health and safety programmes.
–– Includes reporting the level at which each
committee typically operates within the
organisation.
• G4-LA6 - Type of injury and rates of injury,
occupational diseases, lost days, and absenteeism, and
total number of work-related fatalities, by region and
by gender.
–– Reporting to cover all employees, supervised
workers, independent contractors and the rules
applied in recording and reporting accident
statistics.
• G4-LA7 - Workers with high incidence or high risk of
diseases related to their occupation.
• G4-LA8 - Health and safety topics covered in formal
agreements with trade unions.
–– Reporting to include local and global agreements
and the extent (as a percentage) to which health
and safety topics are covered.
(Based on original source G4 Sustainability Reporting
Guidelines, Global Reporting Initiative, 2013)
REVISION QUESTIONS
3. List the elements in the following safety
management systems:
(a) ILO-OSH-2001 Guidelines on Occupational
Health and Safety Management Systems. ILO,
2001.
(b) OHSAS 18001 Occupational Health and
Safety Management Systems: Requirements.
British Standards Institution, 2007.
4. Describe the general principles and objectives of
a health and safety policy document.
5. Outline the arguments for and against
integration of management systems.
(Suggested Answers are at the end.)
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Role and Responsibilities of the Health and Safety
Practitioner
KEY INFORMATION
• Health and safety practitioners develop policy, promote a positive culture, plan to meet objectives, implement
and monitor the policy, and review and audit the whole system.
• Health and safety practitioners require good person management and influencing skills.
• It is important that health and safety practitioners maintain and develop their individual competencies.
• The Institution of Occupational Safety and Health (IOSH) and the International Institute of Risk and Safety
Management (IIRSM) have codes of conduct which members are expected to comply with.
INFLUENCE ON HEALTH AND SAFETY
MANAGEMENT SYSTEMS
Health and safety practitioners are those likely to be
appointed by employers to help them in managing
health and safety in the organisation. Health and safety
practitioners need to have the status and competence
to advise management and employees, or their
representatives, with authority and independence. They
are well placed to advise on many aspects of the safety
management system, such as:
• Formulating and developing health and safety policies
and plans, not just for existing activities but also with
respect to new acquisitions or processes.
• Be involved in establishing organisational arrangements,
systems and risk control standards relating to hardware
and human performance, by advising line management
on matters such as legal and technical standards.
• Establish and maintain procedures for reporting,
investigating, recording and analysing accidents and
incidents.
• Establish and maintain procedures, including
monitoring and other means such as review and
auditing, to ensure senior managers get a true picture
of how well health and safety is being managed (where
a benchmarking role may be especially valuable).
• Present their advice independently and effectively.
• Profiling and assessing risks and organising activities to
implement the plans.
In terms of organisational structure/relationships, health
and safety specialists must:
• Measuring performance by assessing how well the risks
are being controlled and investigating the causes of
accidents, incidents or near misses.
• Support the provision of authoritative and
independent advice.
• Reviewing performance, revisiting plans, policy
documents and risk assessments to see if they need
updating and taking action on lessons learned,
including from audit and inspection reports.
To do this properly, health and safety practitioners need to:
• Be properly trained and suitably qualified.
• Have a direct reporting line to directors on matters of
policy, and the authority to stop work if it contravenes
agreed standards and puts people at risk of injury.
• Have responsibility for professional standards and
systems. On large sites or in a group of companies, they
may also have line management responsibility for other
health and safety specialists.
• Maintain adequate information systems on topics
including law, health and safety management, and
technical advances.
As far as relationships outside the company go, they must
liaise with a wide range of bodies, including:
• Interpret the law in the context of their own
organisation.
• Consultants/contractors.
• Local officials.
• Fire service.
• Insurance companies.
• Enforcing authorities.
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HEALTH AND SAFETY INVOLVEMENT AND
CONDUCT
RESPONSIBILITY TO EVALUATE AND
DEVELOP THEIR OWN PRACTICE
Health and safety practitioners need to be able to
effectively influence the decision-makers, namely the
senior management of the organisation, and also have
the confidence and respect of all workers. It is therefore
essential for them to have good influencing and person
management skills which achieve the desired objectives
without creating conflict, resentment or animosity.
As well as requiring competency in practical risk
management, the standards in occupational health and
safety practice, which this NEBOSH International Diploma
course is designed to meet, also require the practitioner
to be able to evaluate and develop his/her own practice.
This is in line with the IOSH requirement for continuous
professional development, and ensures that the
practitioner maintains and develops competency, keeps up
to date and remains effective.
COMPETENCE AND THE REQUIREMENTS
FOR CONTINUING PROFESSIONAL
DEVELOPMENT
The broad requirements are that practitioners should:
• Reflect on their own practice.
Meaning of ‘Competence’
• Review their practice against appropriate goals.
A competent health and safety adviser can be considered
as having “sufficient training and experience or knowledge
and other qualities to enable him to properly discharge his
professional responsibilities”.
• Set and prioritise goals and targets for selfimprovement.
• Adapt their own practice in the light of changes in
professional practice.
Accordingly the term reflects a combination of knowledge
and relevant experience, although these terms are not
mutually exclusive.
Consequently, in order to achieve this, practitioners need
to:
Continuing Professional Development
(CPD)
• Identify goals and targets which could be set in a
number of ways, e.g. from national standards; from
assessment of current competency; from anticipated
future demands; from personal aspirations; or to meet
organisational needs.
CPD is a feature required by most professional bodies
and is undertaken when the practitioner is considered
competent and satisfies the requirements for full
membership of the professional body. It serves the
following purposes:
• Demonstrating competence and credibility.
• Developing an individual’s career and helping with
appraisal.
• Coping with change by updating skills.
• Thinking about competence and identifying gaps in
knowledge and experience.
• Review their own performance, which might involve
evaluating work results, undergoing appraisals or
formative assessments, or seeking the views of
colleagues and clients.
• Develop their personal action plans and monitor their
achievements.
• Develop and change their own practice, and evaluate
the effectiveness of the developments.
• Anticipate and identify change, and respond
appropriately. This could arise from changes in
professional practice, from national and local
systems or from changes to organisational policy and
procedures.
These requirements can be divided into two principal
components: evaluation, and identification of selfdevelopment needs.
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Role and Responsibilities of the Health and Safety
Practitioner
Evaluating Own Practice
The IOSH has a Code of Conduct which all members are
expected to follow. This requires members to:
Performance Criteria
• Owe a loyalty to the workforce, the community they
serve and the environment they affect.
The practitioner should be able to:
• Evaluate their own practice against set targets and
goals.
• Abide by relevant legal requirements.
• Use a range of valid and reliable evidence to assess
their own work, which includes an assessment of
behaviour and values by others.
• Maintain their competence.
• Involve others in the interpretation of evidence.
• Accept professional responsibility for their work.
• Use evidence to reflect on their own practice and
professional issues.
• Make those who ignore their professional advice aware
of the consequences.
• Accept criticism in a positive manner, and assess its
validity and importance.
• Not bring the professional body into disrepute.
• Revise goals and targets in the light of their reviewing
evidence and performance.
Identifying Self-Development Needs
• Give honest opinions.
• Undertake only those tasks they believe themselves to
be competent to deal with.
• Not recklessly or maliciously injure the professional
reputation or business of others.
• Not behave in a way which may be considered
inappropriate.
Performance Criteria
• Not use their membership or position within the
organisation or Institution improperly for commercial
or personal gain.
The practitioner should be able to:
• Avoid conflicts of interest.
• Set and prioritise clear and realistic goals and targets
for their own development.
• Not disclose information improperly.
• Base goals and targets on the accurate assessment of all
the relevant information relating to their own work and
achievements, including developments in professional
practice and related areas.
• Devise a personal action plan and review it regularly.
• Try out developments in their own practice in a way
which does not cause problems for others.
• Evaluate developments in their own practice and
ensure continued self-development.
An essential ingredient of competence is recognising its
limits - when you begin to get involved in an area which is
beyond your competence and you need to either call in
external expertise, or upgrade your skills.
ETHICS AND THE APPLICATION OF ETHICAL
PRINCIPLES
At the beginning of this element we discussed the moral
reasons for managing health and safety. Ethics is concerned
with moral issues, i.e. the judgments we make and our
resulting conduct. Just because an action we might take
is legal does not necessarily mean it is ethical. This is best
explained by identifying the ethical principles we would
expect practitioners to adopt, such as:
• Ensure information which they hold necessary to
safeguard the health and safety of others is made
available on request.
• Comply with data protection principles and relevant
legislation.
• Maintain financial propriety with clients and employers
and where appropriate be covered by professional
indemnity insurance.
• Act within the law and notify the Institution if
convicted of a criminal offence.
MORE…
You can find out more about the Institution of
Occupational Safety and Health Code of Conduct at:
www.iosh.co.uk/~/media/Documents/About%20
us/COR1081%20Code_%20guidance%20and%20
disciplinary%20procedure.ashx
• Honesty in dealings with clients, etc.
• Respecting others.
• Professional integrity, etc.
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Role and Responsibilities of the Health and Safety
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Similarly the IIRSM has a Code of Ethics which requires
members to:
• Only advise on or undertake tasks where they are
competent to do so.
• Ensure professional competence is maintained and
developed.
In the example above, the likely outcome if the conflict of
interest was declared before the appointment was made
would be for the manager not to sit on the appointment
panel. If, however, the possible conflict was concealed and
later became known, then the manager could be accused
of unprofessional conduct.
• Avoid conflicts of interest.
• Inform the appropriate authority of any illegal or
unethical safety-related behaviour.
• Conduct themselves with fairness when dealing with
others and not engage in discrimination.
• Act as the faithful agent of their clients or employers
and accept responsibility for their own work.
• Assist colleagues in their professional development and
support them in following the Code.
• Not bring the Institute into disrepute.
MORE…
You will find more information on the International
Institute of Risk and Safety Management Code of
Ethics at:
www.iirsm.org/
DEALING WITH CONFLICTS OF INTEREST
A conflict of interest arises when an individual has to
make a decision at work that may affect his or her private
interests.
For example, the safety manager of a large organisation
has the task of appointing a new safety adviser. One of the
candidates for the post is a good friend of the manager,
who expects favourable treatment even though he may
not be the best qualified and experienced candidate. The
conflict of interest dilemma the manager has is whether
to let a personal interest interfere with his professional
judgment.
What should you do when a conflict of interest arises?
There are two aspects to dealing with conflicts of interest:
• Identifying and disclosing the conflict of interest, which
is primarily the responsibility of the individual who is
subject to the conflict. It is clearly better to err on the
side of openness even when the situation is not clearcut, particularly in the long term when the conflict
may become more widely known and more difficult to
resolve, leading to the possible accusation of bias or
even dishonesty.
• Deciding what action (if any) is necessary to avoid or
mitigate any consequences, usually the responsibility of
the manager or department in which the conflict has
arisen. This may range from taking no action at all to, in
extreme circumstances, the resignation or dismissal of
the individual concerned.
© RRC International
REVISION QUESTIONS
6. Identify five external bodies or individuals that a
safety professional may be expected to liaise with
in the course of their work.
7. Identify five examples of how a safety
practitioner would be expected to adhere to
ethical principles.
(Suggested Answers are at the end.)
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Summary
SUMMARY
Reasons for Managing Health and Safety
This element has introduced you to the general principles of health and safety management. We have looked at the
reasons for managing risk and seen that they fall into three categories - moral, legal and economic.
Societal Factors Which Influence Health and Safety Standards and Priorities
We have identified:
• Economic climate.
• Government policy and initiatives.
• Sickness absence and incapacity.
• Industry/business risk profile.
• Globalisation.
• Migrant workers.
• Societal expectations of equality.
• Corporate social responsibility.
Introduction to Management Systems
We have:
• Considered the meaning of the terms:
–– Hazard - something with the potential to cause harm.
–– Risk - expresses the likelihood that the harm from a particular hazard is realised.
–– Danger - a liability or exposure to harm; a thing that causes peril.
• Examined the principles and benefits of risk management on a global perspective.
• Looked at two specific safety management system models which are conceptually very similar:
–– ILO-OSH-2001.
–– OHSAS 18001.
• Considered the benefits and limitations of integrated management systems.
• Identified the following key components of an effective health and safety management system:
–– Management commitment.
–– Policy.
–– Organising.
–– Planning and implementing.
–– Performance review.
–– Audit.
–– Continual improvement.
• Examined the total quality management and environmental management systems:
–– ISO 9000 series.
–– ISO 14000 series.
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Summary
• Discussed the reasons for the introduction of formal health and safety management systems such as:
–– Appropriate allocation of resources and responsibilities.
–– Setting and monitoring performance standards.
–– Establishment of systems for feedback and implementation of corrective action in order to minimise loss.
• Explained the role of the health and safety policy in relation to a health and safety management system and as a
vehicle for the communication of health and safety information.
• Examined the requirements for a written health and safety policy and for recording arrangements.
• Described the general principles and objectives of a health and safety policy document.
• Discussed the implementation, benefits and limitations of the introduction of common health and safety
management principles, standards and systems in organisations operating on a world-wide basis.
• Explained the influence of corporate responsibility and business ethics on health and safety management.
• Examined the role of health and safety in global Corporate Social Responsibility (CSR) guidelines and standards
(United Nations Global Compact; SA8000; Global Reporting Initiative).
Role and Responsibilities of the Health and Safety Practitioner
• We have established that health and safety practitioners should:
• Be able to advise, develop and influence the decision-makers.
• Be able to advise management and employees on various aspects of health and safety.
• Be suitably trained and qualified, and able to perform necessary functions.
• Establish suitable relationships both within their own organisations and with outside bodies and individuals.
• Evaluate and develop their own practice, e.g. continuing professional development.
• Adhere to the ethical policy of their professional body.
© RRC International
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Exam Skills
INTRODUCTION
It should go without saying that to achieve the NEBOSH International Diploma you will need to work carefully
through your course. But you also need to perform when it really matters - in the exam.
As you work through the course you will build up your confidence in preparation for the exam day.
Before we get any further, let’s just outline some basic information about the exam itself:
• You have three hours to complete the exam, plus 10 minutes reading time.
• There are two sections:
–– Section A: six compulsory question (10 marks each).
–– Section B: you can choose to answer three questions from five on the paper (20 marks per question).
So there are 120 marks available in total.
The exam questions require you to demonstrate your knowledge and understanding of the elements you have
studied as part of your course – and to show that you can apply your knowledge and understanding to both familiar
and unfamiliar situations.
That might sound daunting, but basic exam technique is really quite simple (as long as you know the information, of
course!). Essentially, what you need to do is:
• Step 1: Read each question carefully.
• Step 2: Review the marks available (consider how long you should spend on the question and how many points
of information you need to include).
• Step 3: Highlight the key action words.
• Step 4: Read the question again.
• Step 5: Plan your answer (using mind maps, bullet points, etc.) so that you have a structure to work to.
• Step 6: Answer the question in full, keeping a close eye on the time (allow 15 minutes for a Section A, 10 mark
question, and 30 minutes for a Section B, 20-mark question).
You will find more guidance as you work through the course along with plenty of sample/practice questions. It’s
really important that you complete these and get in touch with a tutor if you have any queries or there is anything
you are struggling with.
HINTS AND TIPS
Taking notice of the action verbs when answering questions is essential! NEBOSH has published the following
guide to understanding the action verbs:
Action Verb Meaning
1-28
Define
Provide a generally recognised definition
Describe
Give a word picture
Explain
Give a clear account of, or reasons for
Give
Provide without explanation (used usually with the instruction “give an example of…”
Identify
Select and name
Outline
Give the most important features of (less depth than “explain” or “describe” but
more depth than “list”)
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Exam Skills
We have provided some sample answers that a student may give, together with some possible answer points that
the examiners indicated that they would expect to see covered. They are summarised from examiners’ reports, but
neither the student response nor the possible answer points are model answers. The possible answers are also
NOT provided as a full answer – in an exam you would need to expand upon the bullet points, taking into account
the action verbs, in order to answer the question correctly. Providing the examiner with such a brief answer would
not attract good marks.
HINTS AND TIPS
As a rough guide, you will be expected to provide one answer point for each mark available in a sub-question,
i.e. two points should be included to gain full marks for a two mark sub-question, eight points for an eight mark
sub-question, etc.
However, if you have time, try to include an extra answer point or two where you can – this will increase your
chances of gaining full marks.
Be aware of your timing. It’s important not to spend too long on a particular question and run out of time at
the end as a result. The real key to success is answering all the questions you need to and answering them well!
You will find more guidance as you work through the course along with plenty of sample/practice questions. It’s
really important that you complete these and get in touch with a tutor if you have any queries or there is anything
you are struggling with.
© RRC International
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Exam Skills
QUESTION
An organisation is proposing to move from a health and safety management system based on the International
Labour Organisation ILO-OSH-2001 model to one that aligns itself with BS OHSAS 18001. Outline the possible
advantages AND disadvantages of such a change.
(10)
APPROACHING THE QUESTION
Now think about the steps you would take to answer this
question:
Step 1: Read the question carefully.
Step 2: Next, consider the marks available. This question
is worth 10 marks so you are expected to provide around
ten/twelve different points of information; the question
should take around 15 minutes to answer.
Step 3: Now highlight the key words. In this case. the
question might look like this:
An organisation is proposing to move from a health and
safety management system based on the International
Labour Organisation ILO-OSH-2001 model to one that
aligns itself with BS OHSAS 18001. Outline the possible
advantages AND disadvantages of such a change.
(10)
Step 4: Read the question again to make sure you
understand it and have a clear understanding of the two
management systems it is asking about. (Re-read your
notes if you need to.)
Step 5: The next stage is to develop a plan – there are
various ways to do this. A common approach is to outline
the advantages and disadvantages between the two
health and safety management systems. Remember that
your answer must be based on the key words you have
highlighted.
Step 6: Now you are in a position to have a go at
answering the question. Provide your answer in table form
only at this stage, bullet points and an explanation of each
point. Hint – integration of systems is an important factor!
HINTS AND TIPS
Don’t worry too much about the grammar and
spelling in your answer, but the Examiner MUST
be able to understand what you are trying to say.
There must be a logical flow to the information you
provide and this is where your Answer Plan is so
important.
Also remember that the Examiner MUST be able to
read your handwriting – if they can’t read what you
have written they can’t award you any marks!
SUGGESTED ANSWER OUTLINE
Advantages and Disadvantages of moving from ILO
OSH 2001 to OHSAS 18001
Possible Advantages
• Integration of systems – a move to OHSAS 18001
would facilitate easier integration with BS EN ISO
14001 and ISO 9001:2008 to produce an integrated
management system
• Publicity – if opting for external certification it is
an opportunity to promote the company through
having an independently verified system
• Benchmarking – easier to benchmark performance
with other companies that have this certification
• Continual improvement – shows the company is
committed to continually improving its performance
When you have finished have a look at the following
comments and guidance.
The following is an answer that a student might have
produced in the examination room.
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Exam Skills
Possible Disadvantages
• Although OHSAS 18001 is a well-known standard, it
may produce a system that significantly exceeds the
minimum legal standard. Regulators, however, tend
to prefer the simple and straightforward approach
offered by systems based on ILO-OSH-2001,
which conform more closely to the basic legal
requirements
• Costs – costs involved in changing to this system,
including registration, optional external certification,
changes to standards/paperwork, etc.
• Costs in terms of time – changing from one
system to the other will involve a lot of time from
management, staff and H&S professionals
• Paperwork – increased paperwork to get certificated
by the awarding body
• Possibly too complicated – a system based on
OHSAS 18001 may be more than what a small or
medium-sized company really needs and may be too
difficult to implement for that reason
• Audits for OHSAS 18001 compliance may not be
conducted by auditors with detailed health and
safety knowledge
• Audits may not involve the company’s H&S
professionals if integrated with other systems such
as quality or the environment
HINTS AND TIPS
A question that asks you to “outline” something,
expects you to give the key features of something –
a brief explanation or description.
© RRC International
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Exam Skills
POSSIBLE ANSWER BY EXAM CANDIDATE
IILO-OSH-2001 follows a tried and tested approach, which has been used by quality organisations for a number of years
and has been championed by the regulators. It is used by companies of all types as a ‘starting point’ for building a safety
management system because it has the advantage of being relatively simple and straightforward and does not require
the approval of an external body in the same way as other systems such as OHSAS 18001 do. In essence, a company can
simply set up its systems using the framework provided by ILO-OSH-2001 without the need to go through potentially
costly and time-consuming certification processes. ILO-OSH-2001 may be perfectly satisfactory for a small business that
does not need to go to the expense and trouble of developing a more sophisticated system like OHSAS 18001. However,
as the business grows, its management systems inevitably become more complex and so it may consider moving to OHSAS
18001, which offers an integrated solution.
External, third party certification is available for BS OHSAS18001. If a company chooses to use this option, it will incur
initial and on-going costs, including extra paperwork and activities to source information, procedures, etc. However, this
could potentially strengthen the organisation’s image, as this is done by an outside agency, rather than being done inhouse, and would be seen as more independent. By achieving the OHSAS 18001 standard, the company would be able
to promote its business within the local community and secure orders/work with organisations that require an externally
certificated standard.
If the organisation already has other certificated systems such as BS EN ISO 14001:2004 or BS EN ISO 9001:2008, they
may be able to integrate the systems to save money, as well as helping to embed H&S into the organisation. Other benefits
from moving to a system based on OHSAS 18001 include the opportunity to undertake an initial review and measure
the organisation’s current practices to establish where improvements can and/or should be made. The process allows a
company to actually measure the improvements it has made.
The final thing to consider with the new system would be that 18001 looks at ‘continuous improvement’ as one of its
central themes, so the organisation can look at getting better performance over a period of time.
REASONS FOR POOR MARKS ACHIEVED BY CANDIDATES IN EXAM
An exam candidate would achieve poor marks for an answer that did not:
• Demonstrate a clear understanding of the differences between the systems.
• Identify BS OHSAS 18001 as an integrated management system.
• Outline the possible advantages and disadvantages of moving from one management system to another.
• Concentrate on advantages and disadvantages of each system and strayed into providing a description of the
components of each system.
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v2.1
LOSS CAUSATION AND INCIDENT
INVESTIGATION
ELEMENT
2
LEARNING OUTCOMES
On completion of this element, you should
be able to demonstrate understanding
of the content through the application
of knowledge to familiar and unfamiliar
situations and the critical analysis and
evaluation of information presented in
both quantitative and qualitative forms. In
particular you should be able to:

Explain
theories of loss causation.
the quantitative analysis of accident/incident
Explain
and ill-health data, limitations of their application,
and their presentation in numerical and graphical
form.

Explain
the external and the internal reporting and
recording systems for loss events (injuries, ill health,
dangerous occurrences) and near misses.
loss and near-miss investigations;
Explain
the requirements, benefits, the procedures,
the documentation, and the involvement of
and communication with relevant staff and
representatives.
© RRC International
Unit IA – Element IA2: Loss Causation and Incident Investigation
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Contents
THEORIES OF LOSS CAUSATION
Accident/Incident Ratio Studies
Domino and Multi-Causality Theories
Immediate, Underlying and Root Causes
Reason’s Model of Accident Causation
Revision Questions
2-3
2-3
2-4
2-7
2-8
2-9
QUANTITATIVE ANALYSIS OF ACCIDENT AND ILL-HEALTH DATA
Calculating Loss Rates from Raw Data
Statistical and Epidemiological Analyses in the Identification of Patterns and Trends
Presenting and Interpreting Loss Event Data
Principles of Statistical Variability, Validity and the Use of Distributions
Revision Question
2-10
2-10
2-11
2-11
2-15
2-16
REPORTING AND RECORDING OF LOSS EVENTS (INJURIES, ILL HEALTH, DANGEROUS OCCURRENCES) AND
NEAR MISSES
Reporting Requirements and Procedures
Internal Reporting and Recording
Revision Questions
2-17
2-17
2-19
2-27
LOSS AND NEAR-MISS INVESTIGATIONS
Purposes of Accident Investigation
Investigation Procedures and Methodologies
Communications Focusing on Remedial Actions and Lessons Learnt
Use of Failure Tracing Methods as Investigative Tools
Revision Questions
2-28
2-28
2-30
2-34
2-34
2-34
SUMMARY
2-35
EXAM SKILLS
2-37
2-2
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Theories of Loss Causation
KEY INFORMATION
• Incident studies have demonstrated that in any organisation there is a relationship between the number of major
incidents and those with less serious outcomes.
• The Single Cause Domino Theory suggests that in an accident there is a sequence of events or circumstances that
precede the harm, i.e.
–– Ancestry (i.e. upbringing).
–– Fault.
–– Unsafe act.
–– Accident.
–– Injury.
• Multi-causal theories suggest that preceding an incident there is a combination of causal factors at each level that
may combine to lead to the loss event.
• Reason’s model of organisational accidents states that for a major accident to occur a series of defences must be
defeated for the hazard to lead to a loss event. Unsafe acts may cause the failure of the defences. Unsafe acts are
made more likely by local conditions in the workplace.
Other researchers have produced similar accident ratio
triangles:
ACCIDENT/INCIDENT RATIO STUDIES
There is no shortage of data on incidents such as accidents
or near misses. Some researchers have studied the
figures in detail and concluded that there appears to be
a relationship between the numbers of different types of
accident.
Labour force survey 1990
F. E. Bird used accident data to produce the following
accident triangle:
UK accident data
Bird’s accident ratio triangle
© RRC International
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Theories of Loss Causation
DOMINO AND MULTI-CAUSALITY THEORIES
One of the duties of the safety practitioner is to keep
details of accidents and ill-health conditions and carry
out investigations. The law requires certain accidents
and occupational diseases to be reported. Often the
information that is recorded at the time of an accident
is not adequate for the purpose of investigation into the
cause, and so is certainly inadequate for the purpose of
preventing the accident happening again.
For example, the report form may ask for the nature and
cause of the injury. This could be written as:
Heinrich’s accident triangle
The actual figures vary between the different accident
triangles, but the important thing to note is that for every
major incident or fatality, there are many more less serious
or near-miss incidents.
Analysis also shows that:
• It is invariably a matter of chance whether a given event
results in injury, damage, or a near miss, i.e. near misses
could so easily become more serious incidents.
• Near-miss/less-serious incident data can, therefore, be
a useful predictor of accident potential.
• All events are due to failure to control – so we can
learn from even minor incidents.
The data from these triangles has a number of limitations
that you need to think about before trying to apply it:
• Not every near miss or minor incident involves risks
which could actually have led to a serious incident or
fatality.
• Nature of injury - cut finger.
• Cause of injury - caught on a sharp piece of metal.
The safety practitioner needs to know a lot more than this
such as:
• Which finger?
• How serious was the cut?
• Was this part of the normal job?
• Should it have been sharp?
• Should it have been there?
• How should it have been handled?
A good starting point in investigations is to consider the
two basic theories for accident causation.
Note that domino theory presents a simplified model,
which considers only one cause of an accident. Also, in
the Heinrich model, the focus is on immediate rather than
root causes. Both models are highly reactive and cannot be
used to predict the likelihood of accidents.
• Be careful comparing:
–– Different triangles.
–– Different definitions (e.g. lost-time accidents).
–– Different industries (with different types of risk).
• Statistical significance – you need a certain amount
of representative data for a meaningful comparison
between your workplace and industry as a whole.
2-4
Single Cause Domino Theory
According to Heinrich:
“A preventable accident is one of five factors in a
sequence that results in an injury. The injury is
invariably caused by an accident and the accident in
turn is always the result of the factor that immediately
precedes it.”
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Theories of Loss Causation
The five factors in Heinrich’s accident sequence are
summarised in the following table.
Heinrich's accident sequence
Accident Factors
Description
1. Ancestry and
social environment
Recklessness, stubbornness,
greed and other undesirable
traits of character that may
be passed along through
inheritance. Environment may
develop undesirable traits of
character or may interfere with
education. Both inheritance and
environment may cause faults of
person.
2. Fault of person
Inherited or acquired faults
of person such as recklessness,
violent temper, nervousness,
excitability. These constitute
reasons for committing unsafe
acts or for the existence of
mechanical or physical hazards.
3. Unsafe act and/
or mechanical or
physical hazard
Unsafe performance of persons
such as: standing under danger
areas, careless starting of
machines, removal of safeguards
and horseplay; mechanical
or physical hazards such as
unguarded gears or points of
operation, insufficient light, which
result in accidents.
4. Accident
Events such as falls of persons,
striking of persons by flying
objects, etc. are typical accidents
which cause injury.
5. Injury
Fractures, lacerations, etc. are
injuries which result directly from
accidents.
If this sequence is interrupted by the elimination of even
one of these factors, the injury cannot occur and the
accident has been prevented. In the case of the accident
sequence, perhaps the easiest factor to eliminate is
Number 3, the “unsafe act and/or mechanical or physical
hazard”.
The major point that Heinrich makes is that a preventable
injury is the natural culmination of a series of events or
circumstances which occur in a fixed logical order. Here an
analogy can be made with a row of dominoes placed on
end, such that if one falls it will cause the next to fall and
so on throughout the series (see figure that follows). If
one of the dominoes is removed, the chain of events will
be halted. In the same way, consider Heinrich’s accident
sequence:
1. Ancestry and social environment.
2. Fault of person.
3. Unsafe act and/or mechanical or physical hazard.
4. Accident.
5. Injury.
© RRC International
Unit IA – Element IA2: Loss Causation and Incident Investigation
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Theories of Loss Causation
Heinrich’s domino sequence
Bird and Loftus extended Heinrich’s theory to take into
account the influence of management in the cause and
effect of accidents, suggesting a modified sequence of
events:
1. Lack of control by management.
2. This permits the existence of basic causes (i.e. personal
and job factors).
3. In turn, this leads to immediate causes (such as substandard practices, conditions or errors).
4. These are subsequently the direct causes of the accident.
5. Finally, this results in loss (which may be categorised as
negligible, minor, serious, or catastrophic).
This modified sequence can be applied to every accident
and is of basic importance to loss-control management.
Multi-Causal Theories
There may be more than one cause of an accident, not
only in sequence, but occurring at the same time. For
example, a methane explosion requires:
• Methane in the explosive range of 5% to 15%.
• Oxygen, or air.
• Ignition source.
The ignition will only happen if these three events occur
together. Each of the three events may, in themselves,
be the end result of a number of different sequences
of events. In accident investigation, all causes must be
identified.
2-6
Usually simple accidents have a single cause, which is why
such events so frequently occur; but the consequences
tend to be of a minor nature. A major disaster normally has
multiple causes, with chains of events, and combinations of
events. Fortunately, they are rare occurrences.
The multi-causal model considers that there may be
organisational, cultural, managerial, etc. causes that
interact and result in an accident. The model is more
complex than the single-cause domino theory and can
be used not only for accident investigation, but also to
prevent accidents if the outcomes of monitoring activities
are analysed. The model can also be linked to more
advanced analysis techniques, such as fault trees and event
trees. The downside is that they are more complex and
therefore take longer to carry out.
Systems Theory
This is another way of looking at a multiple cause situation.
Factories and processes can be viewed as systems, i.e. an
assembly of parts or components connected together
in an organised way to perform a task, with inputs and
outputs, and various kinds of control mechanisms.
A systems approach is often useful in simplifying complex
operations. Part of the system can be taken as a ‘black box’,
with only the inputs and outputs considered.
System failures are prevented or minimised by
components which cannot fail, by backup systems, or
by redundancy built into the system (see Element IA4).
Accidents happen in our system because it includes fallible
components such as machines and human beings. The
system is operating in the failure mode.
You can see the essential features of the multiple causation
approach in the following figure.
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Theories of Loss Causation
Features of the multiple causation approach
IMMEDIATE, UNDERLYING AND ROOT
CAUSES
There are various ways of classifying accident causes.
Remember that the same term may be used by different
people to mean different things – you can check this for
yourself by doing an Internet search on the above terms.
When analysing accidents it is common to distinguish
between immediate causes and underlying causes. The
latter are also sometimes called root causes. The term
used can vary, but the most important thing to remember
is to look beyond the symptoms of the accident. You need
to dig down beyond the obvious (immediate) causes to
discover why it happened, or why it was allowed to happen.
Usually, an accident occurs as a result of multiple chains of
events; following these back will lead to underlying causes,
tackling which can stop similar accidents happening again.
• Immediate cause refers to the direct cause of the
accident, i.e. the actual agent of injury or damage, such
as the sharp blade of the machine.
• Underlying, or root causes are the less obvious
systemic, or organisational reasons for the incident.
We will now look at unsafe acts and conditions in more
detail.
© RRC International
An unsafe act is human performance that is contrary to
accepted safe practice and which may, of course, lead to an
accident. Unsafe conditions are basically everything else
that is unsafe after you take away unsafe acts. So, this is
the physical condition of the workplace, work equipment,
the working environment, etc. which might be considered
unsafe and could therefore foreseeably lead to an accident
if not dealt with.
Note that an unsafe act or unsafe condition alone could
result in an accident. For example, “messing around” is
an unsafe act which could take place in otherwise safe
conditions, but could nevertheless result in an accident.
Similarly, a person could be working in a perfectly safe
manner, using safe equipment and materials, but suffer
injuries as the result of the collapse of a floor affected by
severe woodworm and dry rot. (You could argue, however,
that collapse of the floor was due to an unsafe act, i.e.
failure to inspect the floor and supporting joists and to
calculate the floor loadings.)
According to the accident sequence we discussed earlier,
unsafe acts and conditions are caused only by faults of
persons, and these faults are created by the environment,
or are acquired by inheritance.
The faults themselves generally arise because of
inappropriate attitudes, lack of knowledge or skill, or
physical unsuitability.
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Theories of Loss Causation
REASON’S MODEL OF ACCIDENT
CAUSATION
TOPIC FOCUS
TOPIC FOCUS
However the barriers are not perfect and can be
defeated.
Latent and Active Failures
Active failures are one cause for the barriers to be
defeated.
Rather than using the words “immediate”,
“underlying” or “root” causes, the terms “latent”
and “active” failures are also commonly used.
Following research into a series of disasters,
James Reason (an occupational psychologist)
has developed a model of accident causation for
organisational accidents. An organisational accident
is rare, but if it happens it often has disastrous
consequences (e.g. Piper Alpha, North Sea, 1988).
Reason’s model shows that organisational accidents
do not arise from a single cause but from a
combination of active and latent failures.
Adapted Version of Reason’s Model of Accident Causation
In the model there is a series of defence barriers
between the hazard and a major incident. These
not only prevent the incident, (e.g. containment
of the hazard, safe operating procedures, etc.) but
also provide warning of danger (e.g. an alarm)
and mitigate the consequences (e.g. means of
escape). These multiple layers characterise complex
technological systems such as a chemical plant.
Active failures are those unsafe acts which have
immediate effects on the integrity of the system
and are usually committed by those directly involved
in the task. Such individuals often suffer directly as
a result of the incident and may often be blamed
as well. The cause of the failure will be due to an
error (accidental) or a violation (deliberate). Such
unsafe acts occur regularly, but few will cause the
defences to be penetrated, an example being the
chemical plant operator who opens a valve allowing
a hazardous substance to escape.
The model then shows that the local workplace
factors influence the chance of an unsafe act
occurring. In the case of the hazardous substance
escape, this may be due to a lack of supervision
or training, maintenance failure, unworkable
procedures, etc.
According to the model the local workplace factors
are affected by decisions made at a strategic
level by senior management, government,
regulators, manufacturers, etc. In the case of senior
management this might be lack of recognition of the
importance of occupational health and safety, which
will be reflected in the culture of the organisation
by the behaviour that is considered acceptable. The
management may give safety a low priority with no
commitment and minimal funding. These failures
at the strategic levels, both in the organisation and
the external environment, are described as latent
failures because they remain dormant and possibly
unrecognised until they interact with the local
factors and the unsafe acts and work environments,
and increase the likelihood of an active failure.
When the gaps created by active failures align
with those created by the latent conditions, the
opportunity exists for a serious outcome.
(Continued)
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Theories of Loss Causation
Categories of Unsafe Acts
Unsafe acts of persons may be categorised under the
following headings:
• Operating without authority.
• Operating or working at an unsafe speed.
• Making safety devices inoperative.
• Using unsafe equipment, or using equipment unsafely.
• Unsafe methods, e.g. loading, carrying, mixing.
• Adopting an unsafe position or posture.
• Working on moving or dangerous equipment.
• “Messing/playing around”, e.g. distracting, teasing,
startling.
• Failure to wear safe clothing or personal protective
devices.
• Lack of concentration; fatigue or ill health.
From this list you can see that unsafe acts may either
be deliberate violations (sometimes called ‘active’) or
unintentional errors (sometimes called ‘passive’). We
discuss these ‘human factors’ in detail in Element IA7.
Categories of Unsafe Conditions
The following categories describe unsafe conditions from
which an accident may result:
• Inadequate guarding; guards of inadequate height,
strength, mesh, etc.
• Unguarded machinery, or the absence of the required
guards.
• Defective, rough, sharp, slippery, decayed, cracked
surfaces.
• Machines/tools designed with insufficient attention to
safety.
• Unsafe arrangements, poor housekeeping, congestion,
blocked exits.
• Inadequate lighting, glare, reflection.
REVISION QUESTIONS
• Inadequate ventilation, contaminated air.
• Unsafe clothing - no goggles, gloves or mask.
• Unsafe processes - mechanical, chemical, electrical,
nuclear.
• Hot, humid or noisy environment.
1. Outline the five factors in Heinrich’s accident
sequence.
2. How does Bird and Loftus’ theory of accident
causation differ from Heinrich’s?
3. According to Reason, what in an organisation are
“latent failures”?
4. What important principle of accident causation
theory do accident ratio studies illustrate?
(Suggested Answers are at the end.)
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Quantitative Analysis of Accident and Ill-Health Data
KEY INFORMATION
• The amount of injury and ill health in a population may be described by calculating the accident/incident
frequency rate, the accident incidence rate, the accident severity rate or the ill-health prevalence rate.
• Bar charts, pie charts and line diagrams can be used to represent incident data in a graphical format.
• Statistical variation within a population may be described using a normal distribution.
CALCULATING LOSS RATES FROM RAW DATA
GLOSSARY
INCIDENCE
Incidence reflects the number of new cases of a
particular event in a population over a given time
(e.g. a year) and is often used to describe accidents
as each accident is a “new” event.
TOPIC FOCUS
In making comparisons between various industries,
or between work areas in the same factory, it is
useful to consider the commonly used injury ratios.
Accident Frequency Rate
This can be calculated from:
Number of work-related injuries × 100,000
Total number of man-hours worked
PREVALENCE
Prevalence is the total number of cases in a
particular population as a proportion of the total
population. It is often used to represent ill-health
statistics and reflects not only new cases but also
those who continue to suffer.
It is a measure of the number of accidents per
100,000 hours worked.
Accident Incidence Rate
This is calculated from:
Number of work-related injuries × 1,000
Average number of persons employed
It is a measure of the number of injuries per 1,000
employees measured over a defined period, e.g. a
year.
Accident Severity Rate
This is:
Total number of days lost × 1,000
Total number of man-hours worked
It is a measure of the average number of days lost
per 1,000 hours worked and gives the average
number of days lost per accident.
Ill-Health Prevalence Rate
‘Prevalence’ is a term often used to describe ill
health in terms of the proportion of persons
who have the prescribed ill-health condition at a
particular time. The rate is calculated as:
The total number of cases of ill health
in the population × 100
The number of persons at risk
The calculation gives the percentage of the
population with the disease.
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Quantitative Analysis of Accident and Ill-Health Data
STATISTICAL AND EPIDEMIOLOGICAL
ANALYSES IN THE IDENTIFICATION OF
PATTERNS AND TRENDS
Epidemiological analysis may identify a pattern in data
distribution, but it does not in itself give information
on why the pattern is occurring. The pattern must then
be analysed to determine whether causal factors can be
identified and remedial action taken. Epidemiology is
used to identify problems which would not be apparent
from single incidents, e.g. to establish whether a number
of individual cases of food poisoning are linked, and
therefore, may constitute an outbreak.
It is only possible to carry out an epidemiological analysis
when the same type of information is available for all of
the accidents being analysed. Typical data dimensions
include location of accident, time of accident or nature
of injury, etc. Single dimension analysis looks at just
one dimension, e.g. location of accident/incident. The
analysis would involve looking for deviations from what
would be reasonably expected. For example, if work was
spread evenly over a number of sites (with all sites being
of comparable size and carrying out similar jobs) then
you would expect that the numbers of accidents at each
site would be evenly spread. Peaks and troughs should be
investigated.
Statistics is concerned with systematically collecting,
organising and interpreting numerical data. Epidemiology
looks at occurrences of disease in different groups of
people and tries to identify a cause and prevention/
control strategy. The size of groups looked at can be quite
small, e.g. comparing the incidence of a disease between
two factories, or very large, in which comparisons are
made between the populations of different countries.
Epidemiology is so-called because it was initially concerned
with the study of epidemics (a widespread outbreak of
an infectious disease). Both types of analysis are useful in
identifying patterns and trends and giving an insight into
any necessary remedial action that may be required to
overcome a particular problem.
Accident and incident data can be used to measure
whether performance is improving or deteriorating and
to compare data over time, e.g. this year's figures with
last year's. This trend analysis, however, can be affected
by a number of factors other than whether the safety
management systems in place are effective. For example,
an increase in the amount of work carried out by an
organisation may lead to more accidents, but this does
not necessarily mean that the safety performance has
deteriorated. In the same way, a reduction in work may
lead to a reduction in accidents whether or not there are
any changes to the safety management practices.
You can see that the different types of analysis may identify
different patterns or trends which are useful in identifying
what is happening within an organisation, and can help
to identify what actions must be taken to improve safety
performance.
PRESENTING AND INTERPRETING LOSS
EVENT DATA
We will consider some typical ways in which data can be
presented in this section.
Histograms
'Histogram' is the name given to a particular type of
bar chart. It is the diagram used to illustrate a frequency
distribution and it always has the following features:
• All the columns touch each other.
• Both axes have scales:
–– The horizontal axis carries the variable under
consideration.
–– The vertical axis shows the frequency with which
the values of the variable occur.
• The bars are all the same width but the values of the
variable need not begin at zero, i.e. the first column of
the histogram need not touch the frequency axis.
The simplest method of trend analysis is to plot on a graph
the number of accidents or incidents against time. The
measure of time used, e.g. monthly, quarterly, annually,
should be considered, as different time periods may show
the trend better than others. It is also possible to include
a measure of severity, e.g. by plotting the number of days
lost through sickness, or the costs of damage/repair.
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Quantitative Analysis of Accident and Ill-Health Data
Example 1
The following table shows the simple frequency
distribution of the number of days' absence caused by 60
lost-time accidents. (Columns 1 and 2 form the frequency
distribution, columns 3 and 4 are calculated as shown
from the frequency distribution.) The histogram (the next
figure) is based on this table.
Days lost per accident
Days lost per Accident
x
No. of Accidents
Causing Lost-Time
f
Man-Days
Lost
fx
Cumulative
Frequency
fcum
0
3
0
3
1
5
5
8
2
7
14
15
3
12
36
27
4
9
36
36
5
8
40
44
6
6
36
50
7
5
35
55
8
1
8
56
9
3
27
59
10
1
10
60
Totals
60
247
-
Lost-time accidents causing specified no. of days’ absence
(Note: The “mode” is the most popular frequency, i.e. 3
days.)
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Quantitative Analysis of Accident and Ill-Health Data
Example 2
When the variable can take a very large number of values,
it is not practicable to construct either a frequency
distribution or a histogram by the method given in
Example 1; so we divide the values of x into a number of
equal-sized groups and treat each group as a single unit.
Such a distribution is known as a grouped frequency
distribution. (If any calculations need to be carried out,
the groups are represented by the value of x at the midpoint of each as a typical value.)
The following table shows the number of employees in
the given age groups in an organisation that employs 300
people. The next figure is the histogram based on this
table.
Number of Employees in Specified Age Groups
Age Groups
No. of Employees
f
Cumulative Frequency
fcum
Mid-Points
x
16-20
40
40
18
21-25
45
85
23
26-30
55
140
28
31-35
40
180
33
36-40
35
215
38
41-45
30
245
43
46-50
20
265
48
51-55
15
280
53
56-60
12
292
58
61-65
8
300
63
Totals
300
-
-
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Quantitative Analysis of Accident and Ill-Health Data
Number of employees in specified age groups
Pie Charts
Line Graphs
These are circular diagrams, where the pie is divided into
‘slices’ representing the fractions into which the total
of the variable is divided. To construct the diagram, the
quantities must be converted into fractions of 360°. (The
fraction is often expressed as a percentage.) The following
figure is an example.
Rather than using a bar chart or histogram the information
can be displayed as a series of data points connected by
straight lines.
The example below shows the number of accidents
occurring in a year.
Number of accidents occurring in a year
Proportion of lost-time accidents for each department
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Quantitative Analysis of Accident and Ill-Health Data
PRINCIPLES OF STATISTICAL VARIABILITY,
VALIDITY AND THE USE OF DISTRIBUTIONS
Statistical variability refers to the spread or distribution
of a particular variable. Examples include:
• Height or weight of adults.
• Intelligence of people.
• Lifespan of a dog.
• Political views expressed before an election.
• Attitudes to safety in a workforce.
All of these display significant variance. For example, in a
given population relatively few people are extremely short
or extremely tall, whereas many are “in between” these
two extremes and are of “average” height.
What would we do if we wanted to answer the question:
“What is the height of an adult human being (from the
UK)?”
If we measured the height of one person chosen at
random, then whoever we chose could not possibly give
an indication of the variation in height displayed by adult
human beings in a population of many millions. To get over
this problem we must collect a sample of sufficient size so
that we can say that it is likely to be representative of the
whole population. This means that the characteristics of
the sample are more likely to reflect the characteristics of
the whole population under study. In our example in which
we are trying to determine the height of adult human
beings, the sample should contain some short people,
some tall people, approximately equal numbers of men
and women, representatives of ethnic minorities, etc. If
we make sure the sample is representative, there is a good
chance it will provide an accurate indication of the average
height of an adult human.
The normal distribution is actually a family of
symmetrical distributions that have the same general shape
(often described as bell shaped or Gaussian). This type of
distribution tends to predominate in the ‘natural’ world,
e.g. the heights, weights, or intelligence of a sample of
adults, the weights of a harvest of plums from a tree, the
expected life of a batch of light bulbs, etc. You can see
the shape of a typical, normal distribution curve in the
following figure.
Example of normal ‘bell-shaped’ curve
The curve is symmetrical about the average value (or
mean); the mean value coincides with the most common
(or modal) value at the central hump and the distribution
tails off either side of the hump.
This is the general shape you would expect to get if you
plotted the numbers of people with a particular height
(provided you had a large enough sample size). You would
expect a symmetrical bell-shaped distribution about the
average height of that sample of people.
The height of a normal distribution can be specified
mathematically in terms of two parameters:
• The mean (µ) - where the curve is centred.
• The standard deviation (σ) - related to the spread/
girth of the bell-shape.
In general, a normal distribution (N) would usually be
stated in the following shorthand format (the full equation
is actually rather complicated):
N (µ, σ 2)
σ 2, the square of the standard deviation, is known as the
variance.
Normal distributions all share certain properties:
• Continuous data (i.e. data which can take any value not
just integer (whole number) values).
• About 68% of the data values fall within 1σ of the
mean (i.e. 1 σ each side of the mean).
• About 95% of the data values fall within 2σ of the
mean.
• About 99.7% of the values fall within 3 σ of the mean.
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Quantitative Analysis of Accident and Ill-Health Data
So, if you have the mean and standard deviation for
your data, and your data can be modelled by a normal
distribution, you can make predictions about it (using
standardised normal tables). These predictions may
concern the proportion of the population falling within a
particular range of values or the probability of a randomly
chosen item falling within a particular range. This is widely
used in ergonomics (discussed later in Element A7), where
much anthropometric data is assumed to approximate
to a normal distribution – and data gaps are filled on this
basis. An example of its use might be designing some
protective equipment which might fit, say, 95% of the
adult population. Use of this distribution would give
you guidance on the range of fit that you would have
to accommodate. This is provided, of course, the data
approximates to a normal distribution.
You do, however, have to be cautious when interpreting
statistical data. For example, before elections polling
companies try to predict the outcome of the poll. It is
not practical to ask everybody who is eligible to vote,
so they have to identify a much smaller sample that is
chosen at random, to ensure it is characteristic of the
whole population eligible to vote. If the sample is suitably
representative, then this should give a good indication as
to the outcome of the election.
However, it is never possible to say with certainty whether
or not the sample is perfectly representative of the
population, so there is the opportunity for error. One
cause of such error is the sample being too small and not
accurately representing the range of features of the much
larger population. The larger the sample the better!
Two health and safety examples where the use of
representative samples would be beneficial are:
• To design a chair ergonomically suitable for workers on
a production line we would need to have data relating
to the physical features of workers, such as height,
weight, length of leg, etc. so that the chair would be
suitable for the majority of persons we might wish to
employ and would not unfairly discriminate against
those who do not have average characteristics.
• Organisations may wish to measure the safety climate,
a feature which reflects the safety culture. If it was not
possible to survey everybody then we could get a good
indication by identifying and surveying a representative
sample of the workforce.
REVISION QUESTION
5. In a factory with 20 employees there were eight
work-related injuries recorded over a period of
a year. In a year, employees work for 38 hours
a week for a total of 47 weeks. Calculate the
accident frequency rate.
(Suggested Answer is at the end.)
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Reporting and Recording of Loss Events (Injuries, Ill Health,
Dangerous Occurrences) and Near Misses
KEY INFORMATION
• Requirements for reporting and recording certain loss events are set out in the ILO Occupational Safety and
Health Convention (C155) and the accompanying Protocol (P155). Employers should:
–– Record and notify occupational accidents, suspected cases of occupational disease, dangerous occurrences
and commuting accidents.
–– Inform employees about the recording system and notifications.
–– Maintain records and use them to help prevent recurrence.
• Every organisation should maintain records of all significant incidents and have appropriate internal reporting
procedures.
The Protocol (P155) to the Convention (which must
be ratified separately) is specifically aimed at reporting
requirements. We will look at this and the accompanying
ILO Code of Practice (Recording and Notification of
Occupational Accidents and Diseases 1996) in what
follows.
P155 defines a number of accident terms:
REPORTING REQUIREMENTS AND
PROCEDURES
Article 11(c) of the Occupational Safety and Health
Convention (C155) says:
“To give effect to the policy referred to in Article
4 of this Convention, the competent authority or
authorities shall ensure that the following functions are
progressively carried out:…
(c) the establishment and application of procedures
for the notification of occupational accidents and
diseases, by employers and, when appropriate,
insurance institutions and others directly concerned,
and the production of annual statistics on occupational
accidents and diseases;”
“(a) the term ‘occupational accident’ covers an
occurrence arising out of, or in the course of, work
which results in fatal or non-fatal injury;
(b) the term ‘occupational disease’ covers any disease
contracted as a result of an exposure to risk factors
arising from work activity;
(c) the term ‘dangerous occurrence’ covers a readily
identifiable event as defined under national laws and
regulations, with potential to cause an injury or disease
to persons at work or to the public;
(d) the term ‘commuting accident’ covers an accident
resulting in death or personal injury occurring on the
direct way between the place of work and:
(i) the worker’s principal or secondary residence;
or
(ii) the place where the worker usually takes a
meal; or
(iii) the place where the worker usually receives his
or her remuneration.”
Copyright © International Labour Organisation 2002
Copyright © International Labour Organisation 1981
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Reporting and Recording of Loss Events (Injuries, Ill Health,
Dangerous Occurrences) and Near Misses
The basic requirements of P155 are that national
governments should ensure that employers:
• Record and notify occupational accidents, suspected
cases of occupational disease, dangerous occurrences
and commuting accidents. The minimum notification
data should comprise:
–– Enterprise, establishment, employer.
–– Person injured and nature of injury/disease.
–– Workplace, circumstances (accident/dangerous
occurrence/disease).
• Inform employees about the recording system and
notifications.
• Maintain records and use them to help prevent
recurrence.
Notifiable diseases should at least include the prescribed
diseases listed under ILO Convention C121. The schedule
to C121 contains a list of diseases prescribed in relation
to an activity, for which injury benefit should be payable.
Examples include:
• Conditions due to physical agents and the physical
demands of work, e.g. due to ionising radiation,
vibration, noise.
• Infectious or parasitic diseases (in health, vet work,
etc.).
• Additional information:
–– For accidents:
–– Injury - fatal, non-fatal, nature (e.g. fracture),
location (e.g. leg).
–– Accident and its sequence - location of place
of accident, date and time; type, e.g. fall and
related agent, e.g. ladder.
–– For diseases:
–– Name and nature of disease and causative
agent; work giving rise to exposure; duration of
expo-sure (to agent/process); date of diagnosis.
–– For dangerous occurrences:
–– The same enterprise/establishment/employer
details as before.
–– Dangerous occurrence details – date, time,
location, type, circumstances.
UK arrangements for notifiable occupational accidents and
dangerous occurrences require all work-related injuries and
incidents to be reported by telephone or online reporting
forms only.
An example of an official data collection form used in the
UK for notifiable accidents can be found at:
https://extranet.hse.gov.uk/lfserver/external/F2508IE
• Conditions due to substances, e.g. silicosis, asbestosis;
arsenic, chromium, lead poisoning; lung cancer and
mesothelioma caused by asbestos.
The above examples are fairly typical of diseases which
would be notifiable in many regions of the world.
Below are examples of some UK government notifiable
occupational accidents and dangerous occurrences:
• Occupational accidents (fatal/non-fatal injuries), e.g.
fatality, fracture of certain bones, amputation of certain
joints, loss of sight.
• Dangerous occurrences, e.g. gas incidents (such as
poisonings due to incomplete combustion), crane
collapse, scaffolding collapse.
The ILO Code of Practice specifies a minimum
recommended notification dataset:
• Enterprise/establishment/employer details:
–– Employer – name/address, telephone number.
–– Enterprise – name/address.
–– Establishment – name/address, economic activity,
size (workers).
• Injured/diseased person:
–– Name, address, age, sex, employment status,
occupation (also date of birth and length of service
in cases of disease).
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Reporting and Recording of Loss Events (Injuries, Ill Health,
Dangerous Occurrences) and Near Misses
INTERNAL REPORTING AND RECORDING
Use
Similar information as that kept for reportable incidents
should be kept for minor injuries. The safety practitioner
needs to design a suitable form to ensure that he gets the
information that he needs for investigations. Reporting
of near misses requires some careful thought. This could
involve a report by the supervisor, or some sampling and
interview technique.
Accident records are of no help if they are used only
to count accidents. They should be used as a tool to
help control the accidents that are causing the injuries
and damage, and should provide the following useful
information:
Accident Investigation Records
• The conditions, processes, machines and activities that
cause the injuries/damage.
Accident investigation forms are used to give management
an objective tool for measuring and evaluating safety
performance.
• The relative importance of the various injury and
damage sources.
• The extent of repetition of each type of injury or
accident in each operation.
• Accident repeaters, i.e. those workers who tend to be
repeatedly injured, or are involved in more accidents.
Format
The form is completed as a record of the investigation, but
different work environments vary so much, that there is no
such thing as a standard report form. Generally, the report
form should include the following information:
• Name and personal details of the person who had the
accident.
• Date, day and time of the accident.
• Where the accident happened, i.e. department and
specific location.
• How to prevent similar accidents in the future.
Sample Forms
Here you can see four sample forms of the type you are
likely to come across in your work:
• Supervisor’s Report of Injury.
• Incident Investigation Report.
• Injury Report Form 1.
• Injury Report Form 2.
• Occupation of the person involved.
• Job being done at the time.
• Nature of the injury or damage.
• What inflicted the injury or damage.
• Who had control of the cause of the injury or damage.
• What actually happened.
• What things caused the accident, i.e. physical
conditions and acts of persons.
• Immediate remedial action.
• Recommendations to prevent the accident in future.
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Reporting and Recording of Loss Events (Injuries, Ill Health,
Dangerous Occurrences) and Near Misses
Dept:
Name:
Date:
Name of victim
Date of injury
Age
Time
Sex
Works No.
Nature of injury
Where and how did accident occur?
Unsafe acts or conditions
Witnesses
Corrective/Remedial action
Recommendations
Supervisor’s Report of Injury
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Reporting and Recording of Loss Events (Injuries, Ill Health,
Dangerous Occurrences) and Near Misses
Employee (if involved)
Works No.
Department
Section
Incident Date
Reported Date
DESCRIPTION OF INCIDENT (including location, witnesses, and circumstances surrounding incident)
Actual or possible causal factors
Corrective/Remedial action
Signature
Date
Supervisor's Name
Signature
Date
Incident Investigation Report
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Reporting and Recording of Loss Events (Injuries, Ill Health,
Dangerous Occurrences) and Near Misses
VICTIM:
Name
Works No.
Age
Dept
Sex
Occupation when injured
Was this his/her regular occupation?
If not, state regular occupation
How long employed?
ACCIDENT: Date
Time
Place
Description of how accident happened (include name, part, and plant number of machine or tool involved)
Was part of m/c causing accident properly guarded?
Type of feed
Type of guard
Was employee following safety rules?
If not, why not?
Was injury result of lack of ordinary care?
If so, how?
Did some other person cause the accident?
If so, how?
How could recurrence be prevented?
INJURY:
Describe injury and part of person injured
Did victim resume work after medical attention?
If not, was he/she sent home or to hospital?
Home or hospital address
(Continued)
Injury Report Form 1 (page 1)
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Reporting and Recording of Loss Events (Injuries, Ill Health,
Dangerous Occurrences) and Near Misses
WITNESSES:
Give name, number and department:Name
Works No.
Department
Name of foreman/chargehand in charge of work
Name of immediate supervisor
ANY OTHER USEFUL INFORMATION:
Further description/cause of the accident together with sketch:
Completed by
Position
Signature
Date
Injury Report Form 1 (page 2)
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Reporting and Recording of Loss Events (Injuries, Ill Health,
Dangerous Occurrences) and Near Misses
Name
Works No.
Dept
Occupation
Date of injury
Time
Foreman/Chargehand
Nature of injury
Immediate cause of injury
Initial treatment
Name of first-aider
Signature
Date
Is further treatment required? Yes/No
Victim sent home/to hospital?
Will injury cause loss of time? Yes/No
NATURE OF INJURY
WOUNDS:
BURNS:
SITE OF INJURY
laceration
Head
contusion
Face
puncture
Eyes
foreign body
Nose
wet heat (scald)
Teeth
dry heat
Chin
chemical
Ear
friction
Neck
(Continued)
Injury Report Form 2 (page 1)
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Reporting and Recording of Loss Events (Injuries, Ill Health,
Dangerous Occurrences) and Near Misses
NATURE OF INJURY
SKIN:
SITE OF INJURY
dermatitis
Throat
irritation
Shoulder
rash
Arm
FRACTURE
Elbow
SPRAIN
Wrist
STRAIN
Hand
PAIN
Fingers
POISON
Thumb
OTHER (detail):
Chest
Ribs
Back
Abdomen
Hip
Groin
Leg
Thigh
Knee
Shin
Ankle
Foot
Instep
Toe
Injury Report Form 2 (page 2)
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Reporting and Recording of Loss Events (Injuries, Ill Health,
Dangerous Occurrences) and Near Misses
Form Design
Programs Available
Accident forms should be designed to suit the work
situation, and need to include information that is of use to
the safety practitioner. Some ideas which are worth taking
into account include:
The programs which are of most interest are:
• Requiring the reporter to state if the cause of the
accident is:
A database program can be used to store accident data
in a set format, then retrieve and analyse it. It can search
through the whole of a year’s company accident records
and answer such questions as:
–– Unsuitable working environment.
–– Physical unsuitability.
–– Lack of knowledge or skill.
–– Improper attitude.
• Requiring that six accident factors be stated:
• Spreadsheet.
• How many employees had an accident on a Friday?
• How many accidents involved a broken arm?
• Who had accidents involving a power press?
–– The agency - the object or substance involved.
–– The agency part.
–– The unsafe mechanical or physical condition.
–– The accident type.
–– The unsafe act.
–– The unsafe personal factor.
• UK HSE booklets often identify causes found as a
result of a detailed study. Deadly Maintenance was an
investigation into maintenance accidents, and listed the
causes as:
Absence of a safe system of work
46%
Defective or inadequate equipment
18%
Human factors or errors
13%
Poor design
4%
Unauthorised activity
5%
Management failure
6%
Not known
8%
Taking some of the above ideas, any accident or injury
report form should at least require the person reporting an
accident to say whether, in their opinion, the cause was:
• An unsuitable working environment.
• Lack of a safe system of work.
• Unsafe or inadequate equipment.
• Lack of effective instruction or supervision.
• Unsafe personal factors.
Computer Records
Use of personal computers has revolutionised the storage
and manipulation of accident data.
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• Database.
A spreadsheet program is rather like a large sheet of
graph paper, with many rows and columns, where a
number or phrase can be put into each of the spaces.
Columns or rows of numbers can be added, or calculations
performed, using values in the table. The program can also
produce graphs and other pictorial forms of information.
These programs can also be combined, with information
and data being transferred from one to the other. A large
company with a computer department would probably
organise their own programs for accident statistics, but
there are a number of commercial programs for the
purpose in the UK which will accept accident records and
produce the accident form F2508 for the HSE.
Preparing Data Input
It is only possible to retrieve and manipulate data which
has been input first. Many programs will accept data
directly from the keyboard. The person reporting the injury
can be asked a series of questions, with the answers only
involving choosing one item from a list.
There are advantages in having a special form completed
for the purpose. Restricted access to the computer system
maintains security of records. The written record can be
retained as an additional safeguard.
The form must contain all the data required to prepare
report forms for the regulator, and there would be certain
items the employer would need, such as work area, job
type, machinery used, work-in-progress, whether safety
precautions were in place, whether personal protective
equipment was being worn, etc. Care must be taken in the
topics of “cause of injury” and “cause of accident” to avoid
confusion and to get information which is useful later. A
simple format requiring just a tick next to a statement is
preferable.
| Unit IA – Element IA2: Loss Causation and Incident Investigation
© RRC International
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Reporting and Recording of Loss Events (Injuries, Ill Health,
Dangerous Occurrences) and Near Misses
REVISION QUESTIONS
6. According to Protocol P155, what should
national governments ensure that employers do
in relation to loss events?
7. Outline, with examples, the types of disease or
ill-health conditions that should be reported.
8. What useful information can internal accident
reporting and recording systems provide?
(Suggested Answers are at the end.)
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Loss and Near-Miss Investigation
KEY INFORMATION
• Useful guidance exists in the form of the UK HSE publication Investigating Accidents and Incidents (HSG245).
• Loss incidents should be investigated to identify the immediate and root causes, prevent recurrence, assist in any
legal proceedings, and identify any trends.
• An investigation includes examining the scene, evaluating relevant documentation and interviewing witnesses.
• Failure tracing methods such as fault tree and event tree analysis can be used to identify causes of accidents,
particularly where there is an identifiable process.
PURPOSES OF ACCIDENT INVESTIGATION
Here we examine the purpose of loss events investigations
and their role in prevention of recurrence and
identification of trends. We also consider investigation
procedures and techniques to collect relevant information
and draw effective conclusions.
The UK HSE have produced a useful guide entitled
Investigating Accidents and Incidents (HSG245). As well as
identifying reasons and benefits for investigating accidents,
it also outlines a four-step investigation process:
• Step 1: Gathering the information.
• Step 2: Analysing the information.
• Step 3: Identifying risk control measures.
• Step 4: The action plan and its implementation.
We will draw on this guidance in this section.
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The definition of accident includes much more than just
those events which cause an injury. We wish to prevent all
those events and occurrences which might have caused an
injury or damage, as well as those which did. Within the
wider concept of risk management we are interested in the
prevention of all losses. Here we will mostly be concerned
with injury accidents, but the wider concepts need also to
be considered.
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Loss and Near -Miss Investigation
There will always be an immediate cause for an accident,
but we are also interested in finding the underlying and
root causes. This is why we need to consider the chain
of events leading up to an accident; the domino effect
of Heinrich’s theory is a good example. Obviously, any
remedy which starts at the earliest stages will not only
prevent this accident, but a lot of others which have the
same underlying cause.
Accident reports tend to concentrate on “cause of injury”,
but the safety practitioner is more interested in “cause
of accident”. In the case of a multiple cause accident, we
need to consider at the very least if it involves an unsafe
act, an unsafe condition and an unsafe person, and how
these interact.
Since an incident could cause a fatality, a serious injury, a
minor injury, or just a near miss, all incidents should ideally
be investigated. The purpose should be to find the cause,
with the intention of preventing a recurrence, rather than
to apportion blame. An injury usually involves some degree
of blame falling on management, the supervisor, the victim
and his/her workmates.
There are a number of purposes we can identify for
conducting an accident investigation - the main ones
follow.
Discovery of Underlying/Root Causes
The word ‘cause’ has an air of finality about it that
discourages further investigation. If a pipe fails, for
example, and the cause is said to be corrosion, we tend to
think that we know why it failed. This may be true, but it
does not help us prevent further failures. We need to know
the answers to many more questions:
• Was the material of construction specified correctly?
• Was the specified material actually used?
• Were operating conditions the same as those assumed
by the designers?
• What corrosion monitoring did they ask for?
• Was it carried out?
• Were the results ignored?
• Underlying cause: the less obvious ‘system’ or
’organisational’ reason for an adverse event happening,
e.g. pre-start-up machinery checks are not carried out
by supervisors; the hazard has not been adequately
considered via a suitable and sufficient risk assessment;
production pressures are too great, etc.
• Root cause: an initiating event or failing, from which
all other causes or failings spring. Root causes are
generally management, planning or organisational
failings.
Consequently you will find that the terminology used can
vary, but the most important thing to remember is to look
beyond the immediate causes to the management-based
failings that allowed the accident to happen.
Prevention of Recurrence
The purpose of the investigation and report is to establish
whether a recurrence can be prevented by the introduction
of safeguards, procedures, training and information, or
any combination of these. Enforcement agencies look for
evidence for blame. Claims specialists look for evidence of
liability. Trainers look for enough material for a case study.
Safety practitioners look to prevent accidents.
Legal Liability
There is a whole range of legal requirements aimed
at persuading both employers and employees to take
reasonable care of themselves and of others who may be
affected by their acts or omissions. In health and safety, as
in other sectors, everything is fine until something goes
wrong, at which point someone usually has to be held
accountable.
Data Gathering
We can only act on the information we are given,
irrespective of our position. As a safety practitioner, the
way you gather your information will no doubt suit your
requirements and your organisation. It is only after all the
facts have been established that we can begin to interpret
the results.
And so on.
Identification of Trends
As we have discussed earlier, when analysing accidents it
is common to distinguish between immediate causes and
underlying causes. The latter are also sometimes called
root causes and there is some justification for a simple two
stage model. However, the UK HSE publication HSG245
Investigating Accidents and Incidents does make the
following distinctions:
Many accidents may initially appear to be ‘one-offs’, but
after looking at all the relevant information, it may appear
that there is a history of similar incidents, indicating a
trend. It is important to look for existing or developing
trends. For example, a spate of similar minor accidents
could highlight a problem in an organisation which may
be procedural, practical, or human in origin. If not treated,
minor accidents could become major, so the ability to spot
trends is an important skill.
• Immediate cause: the most obvious reason why an
adverse event happens, e.g. the guard is missing; the
employee slips, etc. There may be several immediate
causes identified in any one adverse event.
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Loss and Near-Miss Investigation
INVESTIGATION PROCEDURES AND
METHODOLOGIES
Incident Report Forms
Incident report forms capture and store the data that
you collect in an investigation and act as a systematic
prompt for the investigation process. The amount of detail
required from the investigation will depend upon the:
• Severity of the outcome.
• Use to be made of the investigation and the report.
The report should be as short as possible, but as long as is
necessary for its purpose(s).
The report is not expected to allocate blame, although
some discussion of this is almost inevitable. Reports are
usually ‘discoverable’, which means they can be used by
the parties to an action for damages or criminal charges.
Whether the report is made on a standard form, or
is specially written, it should contain the following
information:
• A summary of what happened.
• An introductory summary of events before the incident
in question.
• Root cause/immediate causes.
The minimum requirement for accident recording will be
established by your local/regional laws. We have already
established the minimum data set recommended by the
ILO, earlier in this element.
We will now look at the four-step accident investigation
methodology described within the UK HSE guide
Investigating Accidents and Incidents (HSG245).
Step 1: Gathering of Relevant
Information
Promptness
The best time to start an accident investigation is as soon
as possible after the event. The less time between the
accident and the investigation, the better and more reliable
the information available will be. Facts will be easier to
determine and more details will be remembered by those
involved, while the conditions are more likely to be closest
to those immediately before the accident.
Equipment
Equipment required will depend on the circumstances:
• Photographic equipment – digital cameras allow
rapid and easy storage and transfer of photographic
evidence.
• Details of witnesses.
• Portable lights may be necessary if electricity is
switched off, or if the accident scene is in a poorly lit
area in a confined space, such as a manhole.
• Information about injury, ill health or loss sustained.
• Sketchpad, pencils and measuring equipment.
• Conclusions.
• Record-keeping equipment including a notebook and
possibly a portable Dictaphone.
• Information obtained during any investigation.
• Recommendations.
• Costings.
• Support materials (photographs, diagrams to clarify).
• The signature of the person or persons carrying out the
investigation.
• The date.
Standardised report forms should be kept at each
workplace and used for each investigation. They should be
returned to a central point for record-keeping and analysis.
It is important that supervisory staff at the workplace carry
out preliminary investigations and complete a report, as
they should be accountable for the work conditions and
need to have personal involvement in failure (accident,
damage or conditions causing ill health). This demonstrates
their commitment and removes any temptation to leave
‘safety’ to others, who may be seen as more qualified.
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• Sample collection equipment, such as jars or other
containers that can be sealed to prevent loss,
evaporation, or contamination. Paper bags, plastic bags,
envelopes and cartons may also be required.
• Tools for cleaning debris or spillages.
• Where explosive or flammable vapours and gases may
be involved, portable gas/vapour detection equipment
should be available. Similarly, where poisonous or
radioactive materials may be involved, the appropriate
detection equipment should be provided.
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Loss and Near -Miss Investigation
Inspection of the Scene
Interviewing Witnesses
The first priority is to help injured people. You may also
need to notify and report the incident to your local
regulator. For serious incidents, the site may need to be
made safe, but otherwise left undisturbed as a ‘crime
scene’ pending an investigation by the police or a health
and safety enforcement inspector.
Any investigation will involve people, and it is easy to
upset them when asking questions about what has been
done or what has not been done. However, casual remarks
made during the site inspection may be revealing, and
the investigator should continue to talk to any personnel
involved near the scene of the accident. This would be an
ideal opportunity to explain that the object of the exercise
is not to apportion blame or to criticise any individual, but
to discover the causes so as to prevent a repetition.
Depending on the severity of any injuries or damage,
the investigator should be present during clearing-up
operations and reinstatement, or clues may be missed.
Failing this, the supervisor should take it upon him or
herself to collect the necessary evidence. You cannot
specify a routine because there are too many possible
variations and circumstances. However, whatever situation
the investigator has to deal with, there are certain things he
or she will need, and there is a logical method of carrying
out the investigation.
In the case of fire investigation, although not essential, it is
helpful if the investigator can be present during the fire, or
at least as soon as possible after it has occurred. The exact
area where the fire started may be more obvious, although
it may be obscured by smoke, and heat may prevent
access to the building. The investigator may get useful
information by watching the activities of the fire-fighters.
He or she will also be able to photograph the course of the
fire, which may subsequently prove useful.
An outline of a routine of investigation applicable in most
cases, which can be modified to suit a particular situation,
is as follows:
• Take a careful, detailed look at the scene of the
accident from a distance, preferably from all sides,
evaluating and noting:
–– The extent and severity of the damage.
–– Damage to surrounding property.
–– Environmental conditions, such as temperature,
ventilation, humidity and illumination.
• Survey the accident site(s) to see if there are any
obvious dangerous physical conditions which may have
been responsible for the accident.
• In the case of spillages, splashes, or other escape of
poisonous, explosive, flammable, or other dangerous
material, it may be necessary to take samples for
subsequent laboratory investigation.
• Where machinery or other equipment has been
involved, it may be necessary to issue instructions
prohibiting its use or repair until the investigation has
been completed.
© RRC International
Types of Witness
There are three types of witness:
• The primary witness is the victim: only he/she will
know exactly the events which led to the accident, and
should be able to give a full account of his/her actions.
• The secondary witness, extremely rare in practice, is
the eyewitness. The problem is that not many people
really see the instant of an accident; their observations
usually begin immediately after the accident has
occurred.
• Tertiary witnesses are those who can offer a variety
of corroborative statements regarding people’s
actions, or environmental information relevant to the
circumstances surrounding the accident.
Putting the Witness at Ease
It is important to put the person being questioned at ease,
and this can be done by explaining the purpose of the
investigation (to discover the causes so as to prevent a
repetition).
The witness will also relax if you encourage his or her
participation and involvement in the exercise, by listening
to any ideas he/she might have about possible preventive
measures. An understanding and friendly manner is
essential to obtain co-operation.
Remember that the witness must be reassured that the
purpose of the interview is not to blame anyone, but to
try to find out the cause and so reduce the possibility of a
recurrence.
Interview Location
Where possible, interviews should be carried out at the
scene of the accident, because it is generally easier for
those involved to explain themselves clearly with the
‘props’ close at hand and be able to point out specific
things and recall their actions related to specific locations.
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Loss and Near-Miss Investigation
Question Phrasing
Step 2: Analysis of Information
It is a good idea to start all questions with What, Where,
When, How or Who. Questions starting with Why
will only put the witness on the defensive and possibly
antagonise them.
This involves examining all the facts, piecing them together
to establish what actually happened, and determining why
it happened. This is often done to some extent while you
are actually collecting data. As data comes in, you may
start developing a theory of what you think may have
happened. This theory may lead you to different areas of
investigation (requiring more data). New data may result
in a refinement of your theory until your theory is realistic
enough to explain all the facts of the case. In general, you
would achieve this by:
Typical questions might be:
• What happened? What did you see? What time was
it?
• Where were you at the time? Where was the victim?
• When did you realise something was wrong?
• How did it happen? How were you involved? How
could it have been prevented?
• Who else was involved? Who else saw it? Who
reported it?
Attitude
The question ‘What happened?’ often generates the
best response and the investigator must listen, without
interruption, to the witness’s account of the accident. The
investigator can always clarify any points at the end.
The investigator should be looking for the witness’s
version of the accident and should not disagree with any of
the statements made or make any judgments on his/her
evidence alone. After all, what a witness believes to have
happened will depend to some extent on just how he/she
perceived the situation, even though this might conflict
with the actual facts of the matter.
Conclusion
When the witness has given their account of the accident,
the investigator should repeat it to the witness to make
sure that he understands it. This also allows the witness to
add any details previously omitted, or expand some points
to make them clearer.
When the investigator and the witness are both satisfied
that a true account has been given, the interview should
end on a positive note by discussing any ideas the witness
has regarding prevention of a similar occurrence. This will
also help to reaffirm the purpose of the interview and
ensure the witness’s further co-operation, should it be
needed.
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• Assembling all your data or evidence.
• Extracting the information that is relevant.
• Identifying any gaps – and following leads to fill those
gaps.
• Discovering the immediate, underlying and root causes
by systematically working through the event (there
are systematic tools for this, but simply asking ‘Why’
repeatedly is a good, simple method).
For systematic consideration of all possible causes and
consequences in complex systems, you can use formal
methods (e.g. fault tree and event tree analysis, ‘cause
and effect’ (or ‘fishbone’) diagrams combined with
‘brainstorming’ methods).
You may need a team-based approach.
Note on Cause and Effect Diagrams
A cause and effect diagram is an analysis tool, sometimes
called a ‘fishbone’ diagram because of its basic structure.
It is also known as an Ishikawa diagram, after the professor
who developed the first one in the 1950s.
The purpose of a cause and effect diagram is to help
people think through the causes of a problem thoroughly,
considering all the possible causes, rather than just the
most obvious ones. It is often used in conjunction with a
brainstorming session.
The following shows an example of a fishbone diagram
applied to the problem of forklift trucks overturning.
| Unit IA – Element IA2: Loss Causation and Incident Investigation
© RRC International
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Loss and Near -Miss Investigation
Fishbone diagram: FLT overturn
Step 3: Identify Control Measures
Identify all possible control measures and then select the
ones that are most suitable (taking account of reasonable
practicability and the effectiveness of different control
types). This may involve justifying selected controls using
formal cost-benefit analysis. We look at control selection in
Element IA5.
Consider also the wider implications of an event. Is this an
isolated event, or is the same event waiting to happen on
a similar piece of equipment in other parts of the plant or
elsewhere? If so, do you need similar controls there too, to
prevent another occurrence?
Involvement of Managers, Supervisors,
Employees’ Representatives and Others in
the Investigation Process
Who should carry out the investigation? Among those
who may make an investigation are:
• The safety practitioner, or one of his staff.
• A member of management.
• The supervisor, foreman, or charge-hand.
Managers
Plan what you have decided to do and do it. This will
involve setting timescales (short-term versus long-term),
allocating specific actions to individuals and checking that
the proposed actions have actually been implemented.
You will remember that many causes of accidents are due
to management systems, or rather the lack of effective
systems. The objective of any analysis or investigative
report is to provide management with a means of deciding
why their policies and procedures failed to prevent
accidents, injuries and ill health. As it is management who
ultimately make the decisions and allocate resources, it is
vitally important that they are actively involved at every
step of the procedures.
© RRC International
Unit IA – Element IA2: Loss Causation and Incident Investigation
Step 4: Plan and Implement
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Loss and Near-Miss Investigation
Supervisors
Usually it is the immediate supervisor of the injured
person, or the supervisor in whose department the
damaged property belonged, who is better qualified to
carry out the investigation than any other member of the
management team, including the safety practitioner:
• He is likely to know most about the situation, so is
best suited to carry out the enquiries necessary for the
investigation to reach a satisfactory conclusion.
• He should know his own workers better than anyone
else does.
• He has a personal interest in establishing the causes
of the accident because accidents affect the efficiency
and morale of his department. He has to explain the
consequences of work stoppage and personal injury to
the members of his production team.
Employees’ Representatives and Others
• Employees’ Representatives
Employees’ representatives have the right to investigate
both accident and ill-health incidents, and this is usually
carried out with approval of management.
• Safety Practitioner
In the case of serious accidents, the immediate
supervisor may not have the necessary authority to
conduct the investigation, so the company safety
practitioner should be in charge of the investigation,
although he will find it helpful to have the assistance of
the supervisory staff. It is essential that the investigator
has the authority to go as far as is necessary to get to
the cause of the problem.
Typical Investigation Procedure
COMMUNICATIONS FOCUSING ON
REMEDIAL ACTIONS AND LESSONS LEARNT
Having investigated the loss event and identified the
immediate and root causes, and remedial action, it is
important that the organisation learns from the event.
Those involved in the same task or similar work associated
with the loss event are likely to benefit most from
the lessons learned, and this might involve changes in
the system of work, further training, etc. The method
of communication will depend on the size of the
organisation. Larger organisations may issue safety bulletins
or newsletters, or even have dedicated briefings on the
incident.
USE OF FAILURE TRACING METHODS AS
INVESTIGATIVE TOOLS
Methods of identifying potential hazards and failures, such
as fault tree and event tree analysis, can also be used to
identify causes of accidents, particularly where there is an
identifiable process. By applying the same techniques in
retrospect, following an accident, rather than at the design
and commissioning stages, they can be useful tools for
the accident investigator. By going through each step of
the process, it is possible to ask whether situations were
normal, or whether a failure, malfunction or error occurred
that could have contributed to the event.
Failure tracing methods, the methodology behind them,
and their applications are discussed in detail in Element
IA4.
MORE…
Investigating Accidents and Incidents - a workbook
for employers, unions, safety representatives and
safety professionals (HSG245) can be downloaded
Details about investigation procedure:
from:
• Typically performed by the supervisor for the section; if
it is serious, then he/she calls in specialists, such as the
safety adviser or engineers.
www.hse.gov.uk/pubns/hsg245.pdf
• The supervisor or specialist should:
–– Discuss and write a report of events from the
injured person.
–– Interview witnesses; check out any discrepancies.
–– Make sketches and drawings; take photographs.
Joint investigation by management and union safety
representatives can be extremely useful. Often an
inspector will accept such a joint investigation as adequate,
and attend later.
REVISION QUESTIONS
9. What are the purposes of accident and ill-health
investigation?
10. What equipment might be required in order to
carry out an accident investigation?
11. What are the four principal stages of an accident
investigation?
(Suggested Answers are at the end.)
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| Unit IA – Element IA2: Loss Causation and Incident Investigation
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Summary
SUMMARY
Theories of Loss Causation
In this element we have considered the various theories of accident causation, including:
• The single cause domino theory, in terms of which a number of factors need to be present in sequence for the
injury to occur. If one factor is removed, the accident will not happen.
• Multiple causation theory, in terms of which there may be additional factors that must be present
simultaneously for the accident to occur.
• Reason’s model of organisational accidents which shows how latent (ongoing) failures increase the likelihood
of active failures.
In accident ratio studies, the accident triangle shows that there appears to be a relationship between the numbers of
different types of accident, e.g. fatal, major, near miss.
The underlying causes of accidents are unsafe acts and conditions:
• Unsafe acts are typically either deliberate violations or unintended errors.
• Unsafe conditions include those of mechanical and physical origin.
Quantitative Analysis of Accident and Ill-Health Data
It is useful to consider the commonly used accident and disease ratios, in order to compare injury and ill-health rates
from different industries, or between work areas in the same workplace.
• Both statistics and epidemiology are useful in identifying patterns and trends.
• Data gathered can be presented and interpreted in various ways, including: histograms, pie charts and line graphs.
When working with statistical data, care must be taken to ensure that samples are representative of the relevant
population of study.
Reporting and Recording of Loss Events (Injuries, Ill Health, Dangerous
Occurrences) and Near Misses
Requirements for reporting and recording certain loss events are set out in the ILO Occupational Safety and Health
Convention (C155) and the accompanying Protocol (P155). Employers should:
• Record and notify occupational accidents, suspected cases of occupational disease, dangerous occurrences
and commuting accidents.
• Inform employees about the recording system and notifications.
• Maintain records and use them to help prevent recurrence.
Internal reporting and recording systems are also essential:
• Accident investigation forms are used to provide management with information for measuring and evaluating
safety performance. Guidelines are given as to what information should generally be included.
• Accident records should be studied and analysed to gain information that can be used to help control accidents.
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Summary
Loss and Near-Miss Investigations
Currently there is no legal requirement for employers to investigate accidents, although it is actively encouraged.
In this element we considered various aspects of accident and ill-health investigations, including the purposes of
investigation:
• Accident investigations are aimed at discovering the immediate, underlying and root causes of an accident.
• Safety practitioners are more concerned with the ‘cause of accident’ than ‘cause of injury’.
• Discovery of underlying causes can help the introduction of practices that may prevent recurrence.
• Trends can be identified.
After an incident, the priority is to help any injured persons. The incident must be classified and the site made safe,
but left undisturbed as much as possible for investigators. There should be a defined procedure for investigating
accidents. The incident report form is the basic document for storing information from the investigation exercise.
The four-step investigation approach of HSG245 is:
• Step 1: Gathering the Information
–– Promptness.
–– Equipment.
–– Inspection of the scene.
–– Interviewing witnesses.
• Step 2: Analysing the Information
–– Failure tracing methods can be used as investigative tools to identify causes of accidents.
• Step 3: Identifying Risk Control Measures
• Step 4: The Action Plan and Its Implementation
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Exam Skills
I’m sure you coped really well with the practice question at the end of Element IA1. It’s important to complete
as many past exam questions as possible so that you develop a really good exam technique.
Your question for Element IA2 is as follows:
QUESTION
Witness interviews are an important part of the information-gathering process of an accident investigation.
Describe the requirements of an interview process that would help to obtain the best quality of
information from witnesses.
(10)
APPROACHING THE QUESTION
SUGGESTED ANSWER OUTLINE
As before, using good exam technique you should:
The following are important factors that the Examiner
might expect you to consider (note that these are
examples only and there may well be other points you
could cover):
• Read the question.
• Consider the marks available. Again there are 10 marks
available so you should spend around 15 minutes
answering the question and provide around 12
different points of information.
• Next you need to highlight the key words; with this
question the key words would include – describe,
information-gathering, interview process, obtain,
information, witnesses.
• An outline plan might include - issues around timing;
environment; atmosphere; listening, etc.
• Planning the interview:
–– Timing of the interview - as soon as possible after
the incident in order to preserve the evidence, and
ensure an accurate recollection of events. However,
the witness must be in a fit state to be interviewed
(e.g. they may be traumatised or injured).
–– Location of the interview - calm and nonthreatening (e.g. not the director’s office, or in
public view in the canteen), free from disruptions,
distractions, e.g. noise, and with water available.
–– Introduce all the persons involved in the interview.
–– Interview witnesses one at a time to prevent
accounts from becoming confused or influenced by
the opinions of others.
–– If appropriate, offer the interviewee a witness or
person to accompany them in order to put them at
their ease, such as a union representative or friend.
• During the interview:
–– Make clear the purpose of the interview at the
outset, so that the witness appreciates that the
intention is to prevent recurrence, not to apportion
blame.
–– Provide an overview of the process that will be
followed so that the witness knows what to expect.
–– Develop a rapport with the witness by adopting a
calm approach. Use questions which will help you
understand the incident and not apportion blame.
–– Keep an open mind as to the causes of the incident
and do not be hindered by hindsight.
–– Set the scene for the interview in order to find out
what the witness actually saw/knows, not what
they think they know from later discussions. For
that reason it is often useful to start the interview
with questions around the build up to the incident.
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Exam Skills
–– Take notes to record the interview and clarify/
summarise throughout to check understanding. It
may be possible to use recording devices such as
video cameras, but these may make the witness
uneasy.
–– Use open questions, such as “tell me about…” or
“what happened…?” rather than leading or closed
questions with yes/no answers.
–– When listening to an answer don’t interrupt but
allow the witness to talk. Use active listening
techniques to demonstrate that attention is being
paid, such as clarifying a point that has been made.
–– It may be beneficial to have photographs, plans, etc.
for the area to hand to aid the discussion, together
with resources such as flip charts for sketching/
recording.
–– Use language that is easy to understand and not
reliant upon technical terms or jargon.
• After the interview:
–– Summarise and agree the interview.
–– Tell the interviewee what will happen next, e.g.
when the findings will be published.
This is a great question because it is not difficult to expand
the bullet points, but remember that there are only 10
marks available and you have 15 minutes in which to
complete your answer.
In a full answer you would need to ensure that you had
described the meaning of the bullet points. Unfortunately
many candidates lose marks by not taking account of the
action verb and providing too brief a response.
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Exam Skills
POSSIBLE ANSWER BY EXAM CANDIDATE
Following an accident you would need to investigate witnesses of the events to establish the facts; to do this you
need to undertake an interview of the witnesses.
The process should take place in a non-confrontational manner, as soon as possible after the event, to keep the facts
fresh and untainted by others’ accounts/recollections.
The room itself should be somewhere that is non-threatening, i.e. not the manager’s office, and should start in a
relaxed manner with an introduction of why the interview is taking place and the need to establish facts to prevent
re-occurrence of similar type of incidents in the future, and learn from what went wrong and why.
Questions should be open, to get responses which give information to the interviewer; the interviewer should allow
witnesses time to answer questions and avoid interruptions and putting words into their mouth. The interviewer
should have an open mind about the incident and make sure they listen sympathetically; sometimes they may need
to highlight that they aren’t the best person to interview the witness as they may be part of the causal factors of the
incident.
Pen, paper, plans, documents, etc. should be available to talk about/discuss at interview, as well as for the interviewer
to use to capture the facts. The interviewer should clarify what they think the witness has said or meant, because
things often get mistaken in the process.
The language used should be appropriate to the incident; summarise the interview and let the interviewee know that
they can always come back later with anything else they may remember about the incident.
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v2.1
MEASURING AND REVIEWING HEALTH
AND SAFETY PERFORMANCE
ELEMENT
3
LEARNING OUTCOMES
On completion of this element, you should
be able to demonstrate understanding
of the content through the application
of knowledge to familiar and unfamiliar
situations and the critical analysis and
evaluation of information presented in
both quantitative and qualitative forms. In
particular you should be able to:

Explain
the purpose of performance measurement
in relation to health and safety objectives and
arrangements.
the need for, and the objectives and
Explain
limitations of, health and safety monitoring systems.

Describe
the variety of monitoring and measurement
techniques.
the requirements for reviewing health and
Explain
safety performance.
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Unit IA – Element IA3: Measuring and Reviewing Health and Safety Performance
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Contents
PURPOSE OF PERFORMANCE MEASUREMENT
Assessment of the Health and Safety Objectives and Arrangements
Review of Current Management Systems
Revision Question
3-3
3-3
3-6
3-7
MONITORING SYSTEMS
Need for Active and Reactive Measures
Objectives of Monitoring
Limitations of Accident and Ill-Health Data as a Performance Measure
Distinctions Between, and Applicability of, Performance Measures
Revision Questions
3-8
3-8
3-8
3-9
3-9
3-10
MONITORING AND MEASUREMENT TECHNIQUES
Range of Measures Available to Evaluate an Organisation’s Performance
Key Elements and Features of Measurement Techniques
In-House and Proprietary Audit Systems
Use of Computer Technology to Assist with Data Storage and Analysis and Production of Reports
Comparisons of Performance Data
Use of Benchmarking
Revision Questions
3-11
3-11
3-12
3-13
3-13
3-15
3-15
3-16
REVIEWING HEALTH AND SAFETY PERFORMANCE
Formal and Informal Reviews of Performance
Review Process
Revision Question
3-17
3-17
3-17
3-18
SUMMARY
3-19
EXAM SKILLS
3-21
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Purpose of Performance Measurement
KEY INFORMATION
Performance measurement serves several purposes:
• It is essential in order to establish whether the policy and its arrangements have been effectively implemented,
including the adequacy of control measures.
• It provides information for the review process, which looks at the effectiveness of the entire health and safety
management system and recommends changes that lead to improvements.
• It measures and rewards success.
• It maintains and improves health and safety performance.
Here we examine the purpose of performance
measurement in health and safety, and its role in assessing
the effectiveness of health and safety objectives, and the
management system generally. We looked at a number
of management system models in Element IA1. The UK
HSE guidance documents Managing for Health and Safety,
HSG65 and Plan, Do, Check, Act - An introduction to
managing for health and safety, INDG275 are excellent
background reading for the subject of measuring health
and safety performance. You can access both these
publications at www.hse.gov.uk.
The first question you might ask is: Why measure health
and safety performance? One obvious answer is: How
else will you know how well you are doing? If you don’t
measure performance, you will have no idea of how far
away you are from where you want to be and whether
your plans are actually working. Purposes of performance
measurement include to:
• Assess the effectiveness and appropriateness of health
and safety objectives and arrangements in terms of:
ASSESSMENT OF THE HEALTH AND SAFETY
OBJECTIVES AND ARRANGEMENTS
Assessing effectiveness of health and safety performance
implies that we must first have both something that can
be measured, and some goal or standard against which to
judge that measurement. As we mentioned in Element IA1,
health and safety management system models all require a
policy statement. This policy statement should be spelt out
in clear objectives. At the very least it should commit the
organisation to compliance with legislation (such as may
be implemented in accordance with the ILO Safety and
Health Convention). It should also commit to continual
improvement.
We need to set objectives in terms of things that can
be measured. A common statement is, “If it cannot be
measured, there is very little chance that it will be done”,
so we need to state objectively what we mean.
TOPIC FOCUS
–– Hardware (plant, premises, substances).
–– Software (people, procedures, systems).
• Measure and reward success (not to penalise failure).
A useful acronym to remember when setting
objectives is SMART. Good objectives need to be:
• Use the results as a basis for making recommendations
for a review of current management systems.
• Measurable - so you know if they have been met.
• Maintain and improve health and safety performance.
• Specific - as to what you want to achieve.
• Achievable - attainable.
• Realistic - realistically achievable with the
resources you have.
• Timely - set a reasonable timescale to achieve
them.
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Purpose of Performance Measurement
In many regions of the world there are legal standards
for chemical contaminants and dust levels, and for noise.
The exposure to some chemicals must be kept as low as
possible, and must not exceed a certain level. The safety
objective could be set lower than this standard. We then
have an objective to aim for. If we achieve this consistently,
an even lower standard can be set. In this way, we comply
with the requirement to reduce the level to as low as
possible.
Similarly, equipment will need to be tested periodically. For
each piece of equipment, the type of test, the frequency of
testing, and the standard can be laid down.
It is possible to create standards with regard to training.
Good practice dictates that certain jobs should only be
performed by qualified or experienced workers. Refresher
training and perhaps even re-testing can be used to make
sure that practical skills are maintained. For example, firstaid qualifications must typically be renewed at specified
maximum intervals, e.g. every three years or so.
Measuring Performance Against
Objectives
When setting objectives, we have to consider performance
standards and indicators. It is easy to set and measure
production standards and there are also standards that can
be set for safety and health. Safety sampling and similar
techniques can be used. The UK’s HSE document HSG65
(see earlier) suggests the use of two measuring systems
with the main purpose of measuring and rewarding success,
not penalising failure:
• Active systems, which monitor the achievement of
objectives and the extent of compliance with standards.
Examples would be monitoring the safety of plant and
equipment; compliance with safe systems of work; safe
behaviour by employees.
• Reactive systems, which monitor accidents, ill health,
incidents and other evidence of deficient health
and safety performance, such as hazard reports.
Investigations into accidents should determine
underlying causes; weaknesses; any need for training;
and changes or replacement required in machinery,
substances or working methods.
Periodically, there will be a review procedure and those
who are filling a post but not performing a role may need
to be replaced. The safety committee (if you have one)
should consist of active members. If something needs to
be done, then it should be made the clear responsibility
of an individual. There is then a standard against which to
measure performance, so the committee is more than just
a ‘talking shop’.
The term “arrangements” can also mean everything that is
stated in this section of the employer’s safety policy. The
arrangements section usually includes such topics as:
• Accident reporting.
• Fire precautions.
• Training.
• Contractors and visitor arrangements.
• Dealing with any hazards in the operation (i.e. control
measures).
Safe methods of work and permit-to-work schemes
would also be detailed. All these arrangements need to be
assessed to make sure that they are (and continue to be)
effective and appropriate and working as intended.
Control Measures
An assessment of the effectiveness and the
appropriateness of the control measures of a company
is another important area of performance measurement,
although this may not be so easy to measure accurately.
Someone has to be in control of the organisation, but
this control also has to be delegated. Since one person is
usually not able to complete the whole task of achieving
the safety objectives, it will have to be divided up and
some degree of control exercised.
• The formal control system can be either authoritarian
or consultative. To be effective, each person needs
to know those areas where he must conform to a
predetermined plan and those areas where he can
exercise some discretion.
• There will also be an informal control system, where
working groups establish and enforce the group norms.
The ideal situation is where the individual and group
targets coincide with the organisational targets.
Arrangements for Actioning Objectives
Performance measurement involves an assessment of the
effectiveness and appropriateness of these organisational
matters. If they do not work, they need to be made to
work.
If each person in the safety organisation has a job
specification and a list of tasks and duties, and there are
expectations of achievement, then it is possible to measure
how effectively these people have performed. What is
needed is some form of ‘measurement by objectives’.
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Purpose of Performance Measurement
Measurement of the degree of control is probably best
achieved by systematic reviews.
• A supervisor would carry out some form of daily
assessment.
• The sectional manager would need to hold a monthly
review.
• A quarterly review might be appropriate for a
department.
• An annual review would be appropriate for the total
organisation.
Control will involve a review of performance, and the
setting of modified objectives for the next period of time.
It is also the time to consider possible conflict situations
and how these might be resolved, and any communication
problems.
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Unit IA – Element IA3: Measuring and Reviewing Health and Safety Performance
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Purpose of Performance Measurement
REVIEW OF CURRENT MANAGEMENT
SYSTEMS
The HSE publication, Managing for Health and Safety,
HSG65, is just one example of a safety management
system. It details the methods of safety management
which should be adopted, and contains a useful diagram
which sets out the principles involved.
The plan, do, check, act cycle based on the approach in HSG65
We are concerned here with the elements of measuring
and reviewing performance, key elements in any system of
management. To manage anything, including health and
safety, we must have objectives or a policy which sets out
what we hope to achieve. We then construct a suitable
organisation and put the plan into effect.
3-6
After a suitable time interval we have to review
performance; either we have achieved what we set out to
do, or we have failed. If we have achieved our objectives,
we can congratulate ourselves and set more difficult
objectives for next year. If we have failed we must find out
why.
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Purpose of Performance Measurement
• Were the objectives impracticable?
• Were resources not available?
• Was the safety practitioner incompetent?
• Should he or she be replaced?
• Should we increase the safety budget?
Every element of the management system can be audited
or examined in detail. We require a system which is
continually being improved.
A management system for health and safety should be in
existence. The one suggested in HSG65 is based on the
Plan, Do, Check, Act cycle, so production managers should
be used to operating along similar lines.
The safety practitioner needs to be in a position to
recommend that safety matters and risk management
principles are incorporated into the company management
systems. The idea that good management involves
accident prevention and loss prevention is a very sound
one. This might involve adding safety and health objectives
to a list of production objectives for each manager.
The integration of production and safety makes for a
profitable and cost-effective organisation. You should be
aware of the cost of accidents. If accident costs and other
losses are deducted from any bonuses paid, or credited
to production managers, then the safety message is
established and the safety culture of the organisation is
assured.
REVISION QUESTION
1. List three purposes for performance
measurement.
(Suggested Answer is at the end.)
© RRC International
Unit IA – Element IA3: Measuring and Reviewing Health and Safety Performance
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Monitoring Systems
KEY INFORMATION
• Monitoring requires a combination of both active and reactive measures to assess whether the health and safety
objectives have been met.
• Active measures check that health and safety plans have been implemented and monitor the extent of
compliance with defined systems, procedures, legislation and standards, e.g. routine inspections.
• Reactive measures analyse data relating to accidents, ill health and other loss causing events.
• Accident and ill-health data may not be wholly reliable:
–– Some incidents may not be reported.
–– Infrequent events may not reflect the effectiveness of current arrangements.
• Data may be qualitative (described by words), quantitative (described by objective numbers), subjective (based
on personal opinion) or objective (unbiased and factual).
NEED FOR ACTIVE AND REACTIVE
MEASURES
No single measure, by itself, will effectively measure
the performance of the organisation. While we will be
favouring the use of active monitoring, there is still a role
for the reactive monitoring of accident and ill-health data;
active means ‘before it happens’, while reactive means
‘after it has happened’.
The essential element is to find some factor that can be
measured and will relate directly to a specific objective in
the safety policy, arrangements or control.
OBJECTIVES OF MONITORING
TOPIC FOCUS
Objectives of Active Monitoring
The objective of active monitoring is to check that
the health and safety plans have been implemented
and to monitor the extent of compliance with:
• The organisation’s systems and procedures
(check that practice reflects the written
procedures).
• Legislation and technical standards.
By identifying non-compliances, steps can be taken
to ensure that any weaknesses are dealt with, so
maintaining the adequacy of the health and safety
plans, and helping to avoid any incidents.
Objectives of Reactive Monitoring
The objective is to analyse data relating to:
• Accidents.
• Ill-health situations.
• Other loss-causing events.
• Any other factors which degrade the system.
It is better to identify, and deal with, any potential
problems by means of active monitoring, rather
than waiting for an event to happen to highlight any
shortcomings in the systems.
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Monitoring Systems
LIMITATIONS OF ACCIDENT AND ILL-HEALTH
DATA AS A PERFORMANCE MEASURE
Accidents in individual workplaces should be rare
occurrences, and there should not be many cases of illness
and disease caused by the work environment. This means
that there are not many cases to count, and the numbers
may not be regarded as statistically significant.
Variations from year to year might be due to pure chance
rather than any accident reduction measures that have
been introduced. This is why we often resort to national
statistics, or even international data, in order to find
significant numbers to target safety programmes.
If we keep data for many years, it is possible to iron out
these fluctuations by finding the moving average. As we
get another year’s, or month’s, figures we are able to enter
this into the average and so identify a trend.
Accident statistics tend to reflect the results of actions
which were taken some time ago, so there is not a rapid
cause and effect situation. It is also unfair to blame a
manager for accident situations when the present situation
is to some extent dependent on actions taken a while ago,
and the present actions will take some time to show. Cases
of occupational disease are, by their very nature, long-term
effects.
Accident data is relatively easy to collect. Serious injuries
are quite difficult to hide. There are a number of standard
calculations of accident rate which are fairly easy to
understand. Management can easily link accidents with
safety performance, so it should not be difficult to discuss
accident reports, and get management to take action.
Accident recording therefore has some value, but it is of
limited use in relation to assessing future risk. There are
problems with under-reporting of minor accidents. Time
off work does not correlate well with the severity of an
injury, because some people will work with a broken arm,
while others take a week off with a cut finger. Also, if
workers are made aware of safety matters, they tend to
report more accidents. The picture may then look worse,
when actually the safety culture is improving.
DISTINCTIONS BETWEEN, AND
APPLICABILITY OF, PERFORMANCE
MEASURES
Active/Reactive
Active means ‘before it happens’, while reactive means
‘after it has happened’. Measuring safety performance
by looking for things before they happen can never be
easy, but this is what the law requires. We carry out risk
assessments to decide what might happen and then take
action. We can certainly measure whether we have taken
action in those areas where the risk assessment suggests
that we do. If an accident occurs then we can no longer
suggest that this is improbable; it needs to be included in
the risk assessments.
Objective/Subjective
• Objective means that it is detached from personal
judgment. For example, an audit question such as:
“How many enforcement notices have been issued
to your company in the last 12-month period?” does
not depend on the personal judgment of the auditor.
However, a poorly phrased objective measure can
distort your view by not taking account of the context
and all the circumstances of the case. Objective
measures are always desirable, but are not always
possible; some things, or facets, resist objective
measurement.
• Subjective means that it depends on someone’s
opinion, judgment, bias, or discretion. As a result, the
person carrying out the measurement will influence the
measurement result. Questions like: “Is housekeeping
adequate?” with no defined standard of adequacy
might get different results from different auditors.
An example of a relatively, though not totally, objective
audit system relating to contractors was described a few
years ago - the principles are still relevant. The system
involved a statement, the contractor’s response, the audit
comment, and a score.
The form used was something like the one in the next
table. The scores are:
0. Totally unsatisfactory.
1. Very little action - unsatisfactory.
2. Some reasonable action - but could be better.
3. As required.
Other scoring systems could be used.
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Unit IA – Element IA3: Measuring and Reviewing Health and Safety Performance
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Monitoring Systems
Example of Objective Safety Scores
Item
Statement or Question
Contractor’s
Response
Audit Comment
Mark
12
Workforce to be trained in use of
fire-fighting equipment.
Agreed
Less than expected
2
13
Safety helmets to be worn at all
times when on site.
Agreed if provided by
owner
Satisfactory
3
14
Contractors to wear distinctive
clothing.
Agreed
Not worn in hot weather
1
15
All waste to be cleared up daily.
Agreed if skip
provided
Usually satisfactory
2
16
All electrical equipment to be
subject to routine inspection as
laid down in owner’s scheme.
Agreed inspection
schedule to be made
Not satisfactory, no list available
0
17
All dump truck drivers to complete Agreed owner and
a course of training.
contractor to share
cost
Satisfactory
3
18
All lighting equipment to be
subject to owner’s scheme of
inspection and test.
Unspecified equipment found
1
19
Who decides when weather
Owner’s site foreman
conditions are too bad for work to
continue?
Only one problem in 6 months
2
Agreed
Scores on safety samples are also quite objective.
Qualitative/Quantitative
• Qualitative means that the data is not represented
numerically, e.g. reports and commentaries, which
although useful are difficult to treat as an accurate
measure.
• Quantitative means that the data describes numbers,
e.g. the number of accidents reported. In such a case
we can see whether there has been an improvement or
a reduction in standard.
Examples of quantitative measures of safety performance
would be:
• Audits.
• Inspections.
• Safety tours.
• Safety sampling.
• Behavioural measures.
• Safety surveys.
• Benchmarking.
REVISION QUESTIONS
2. Give one example each of an active measure,
reactive measure, objective measure and
subjective measure of health and safety
performance.
3. What are the limitations of accident and illhealth data as a performance measure?
(Suggested Answers are at the end.)
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Monitoring and Measurement Techniques
KEY INFORMATION
• Measurement techniques include inspections, audits, safety tours, safety sampling and surveys.
• Audits are an independent assessment of the management system and may be undertaken internally or externally
(often by consultants).
• Benchmarking enables an organisation’s practice to be compared with other comparable organisations that
display excellence.
RANGE OF MEASURES AVAILABLE
TO EVALUATE AN ORGANISATION’S
PERFORMANCE
ACTIVE MONITORING TECHNIQUES
Selecting the appropriate outcome indicator depends on
the chosen objectives, but the following is a range of active
and reactive outcome indicators relevant to a range of
objectives.
Active Monitoring Data
There is a wide range of data that can be collated to assess
health and safety performance, some of which are active –
such as the uptake rate for toolbox talks, or the completion
of risk assessments against the target.
TOPIC FOCUS
Health and Safety Audits
The health and safety audit should be an in-depth,
systematic, critical investigation into all aspects of
safety. It needs to include management systems,
policy, attitudes, training and practice.
Workplace Inspections
These data cover the extent to which plans and objectives
have been set and achieved, and include:
A workplace inspection involves a competent person
walking round a part of the premises, looking for
hazards or non-compliance with legislation, rules
or safe practice, and taking notes. The task is made
easier and more methodical if a checklist is used.
• Perceptions of management commitment.
Safety Tours
• Specialist staff.
A safety tour follows a predetermined route through
the area or workshop and can be conducted by
a range of personnel from works managers to
supervisors and safety representatives. Such tours
typically last only 15 minutes or so and may be
carried out at weekly intervals to ensure that
standards of housekeeping are acceptable, gangways
and fire exits are unobstructed, and hazards are dealt
with quickly.
• Risk assessments.
• Safety policy.
• Extent of compliance.
• Training.
• Health and safety committee meetings.
Reactive Monitoring Data
Safety Sampling
Other data are reactive, and are typically based on
accidents and incidents that have occurred. They include:
• Near misses.
This is an organised system of regular random
sampling. Its purpose is to obtain a measure of safety
attitudes and possible sources of accidents, by the
systematic recording of hazard situations observed
during inspections made along predetermined
routes in a factory or on a site.
• Damage-only accidents.
Safety Surveys
• Reportable dangerous occurrences.
A safety survey is a detailed examination of a
particular safety aspect. It could involve, for example,
a detailed inspection of all aspects of fire-fighting
equipment; examining all the safety devices on
machines; or checking all the emergency exits.
• Health surveillance reports.
• Cases of occupational diseases.
• Lost-time accidents.
• Three-day, lost-time accidents.
• Reportable major injuries.
• Fatalities.
• Sickness absences.
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Monitoring and Measurement Techniques
KEY ELEMENTS AND FEATURES OF
MEASUREMENT TECHNIQUES
Workplace Inspections/Safety Tours/
Safety Sampling
Health and Safety Audits
The advantage of workplace inspections is that the
inspection can be far more frequent than an audit. To be
an effective measure, the workers as well as management
need to be involved, as this gives them ‘ownership’ of
the safety process. Management is able to demonstrate
commitment to safety and it is possible to get a clear
picture of problem areas and to take quick and effective
action. A scoring system is required if comparisons
over time, or with other sections, are to be made. Such
an inspection usually goes under the name of safety
sampling if it concentrates on a few specific points. A
safety tour follows a set route.
Health and safety audits are ideally done by an external
organisation, or a special unit from head office in the
case of multi-site operations. The purpose is to assess
the extent to which the elements of the system are still
effective, and whether any action is necessary to avoid
accidents and other losses. To be used as a measure,
standards need to be set in the key areas. A scoring system
can be introduced if the intention is to hold managers
responsible for standards in their area of influence.
There are some points against the use of audits:
• Audits are time-consuming and costly.
• It is not feasible to carry out a full audit more than once
a year.
• There are likely to be a lot of things to correct, and
some of these may take time to complete.
• If there is a long time between the recommendation
being made, and the solution being put into effect, the
value of the audit is reduced.
There are a number of proprietary audit systems which
are available, sometimes referred to as the International
Safety Rating System (ISRS). Often these are computerbased and require answers to set questions. If there are to
be comparisons between departments then there will need
to be some uniformity. The scoring system should give
weighting to significant safety performance. Human factors
and attitudes need to be a major element of the audit, but
these are not so easy to measure or score.
3-12
Points to watch are that if the inspections or sampling are
too frequent, it is possible that an action point required by
the previous inspection will not have been corrected when
the next inspection takes place. Any scoring system used to
compare sections must be shown to be fair and impartial.
You will be aware that some inspectors are lenient, and
others are very strict; some inspectors just have to find
something wrong. The training and experience of the
inspectors is important. Often inspections find minor
matters that are not really likely to cause accidents and fail
to find larger potential hazards.
Safety Surveys
Safety surveys make sure that aspects of safety are not
overlooked in the general run of inspections. A safety
survey generally results in a formal report and an action
plan to deal with any findings.
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Monitoring and Measurement Techniques
IN-HOUSE AND PROPRIETARY AUDIT
SYSTEMS
The following is one of several methods that can be used:
An important feature of the monitor and review process is
that of the safety audit. The audit should suit the industry
and the work situation involved, but be independent of the
normal workforce. It must be cost-effective, help to avoid
future problems and lead to real improvements. There
are quite a number of proprietary audit systems available,
either form-based or computer-based.
Types of Safety Audit
The term ‘safety audit’ is used in several different ways. It
can be:
• Nothing more than an inspection, safety sampling, or a
safety survey - it is best not to use the term ‘audit’ for
this situation.
• A detailed internal investigation of the safety systems
and practices of the organisation - such an audit would
probably be carried out every year by a team consisting
of the safety practitioner and production managers.
They would use a specially prepared checklist covering
areas such as: commitment, communications, safety
training, access, machinery, electrics, lifting equipment,
mobile equipment, materials handling and storage, fire
prevention, housekeeping, PPE, etc. A report will be
prepared for management and action will be required.
• An external safety audit, carried out by an outside
organisation. Its basic objective is to examine all aspects
of the company which relate to safety and health to
see if statutory requirements are being complied with.
Since audit includes the competence of the safety
specialist and the management, it cannot be carried
out by people closely associated with the subject of the
audit. It is similar to a financial audit, which checks on
the ability and the integrity of finance personnel.
The external safety audit is a critical examination of an
industrial operation in its entirety to identify potential
hazards and levels of risk. Its aims are to:
• Ensure the company is complying with the relevant
legislation.
• A representative of the organisation carrying out the
audit meets the client company’s management to
define the exact terms of reference.
• An audit team is formed under the leadership of a coordinator.
• The audit is divided into a number of basic headings
in accordance with the terms of reference. The
headings are allocated among the team. Examples
include: company information, personnel, premises,
organisation, training, technical expertise, incident
history, documentation, etc.
• The team visits the company and acquires information
under the headings by means of observation,
discussion with management and analysis of records
usually using prepared checklists and flowcharts.
• The information is collated and a report is presented to
the company’s management.
Developments in technology, public attitude and
legislation are likely to increase demand for audits; they
could become as common as the financial audit is in
accountancy.
USE OF COMPUTER TECHNOLOGY TO
ASSIST WITH DATA STORAGE AND ANALYSIS
AND PRODUCTION OF REPORTS
Availability and Types of Software
Computer programs for data storage or analysis will be
based on either a database or a spreadsheet format. There
are likely to be quite a number of related programs which
are called in to perform tasks.
The spreadsheet can be likened to a very large sheet of
graph paper or a very large table that can be filled with
data. Words or numbers or a mathematical formula can be
entered into each square. Columns and rows can be added,
and quite complicated calculations performed between
values in the various squares. This type of program can also
produce graphs and other visual presentations of the data.
• Make certain the methods of risk control are both
effective and economically sound.
Audits are generally undertaken by multidisciplinary teams.
Individual members should have a good knowledge of legal
requirements, an understanding of reasonable practice in
the industry and the ability to communicate with all levels
of personnel within the organisation. In many companies
the expertise is not readily available and so audits tend to
be undertaken by external specialists, such as consulting
engineers acting independently or employed by insurance
companies.
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Monitoring and Measurement Techniques
In-House or Proprietary?
Often a decision has to be made as to whether such
a program is produced in-house, or purchased from a
supplier. Many organisations can produce their own
programs that do exactly the job required.
Before purchasing a proprietary audit system, it is as well to
decide a number of factors:
• What do you want it to produce?
• Where is the data? Is it to use data on name, address,
etc. from another source, or do you duplicate this for
safety purposes?
• If organisational data is linked, will it be possible to
access confidential information?
• Is the hardware (computer items) compatible with the
software (the programs)?
The database program is similar and can store data in
the form of numbers or phrases. It is rather like having
lots of spreadsheets (or tables) which can be linked by
common ‘fields’ or storage areas. A database program
could store information about injuries with a separate,
but linked, field for name, number, address, work area,
injury, time of accident, reason for accident, time off
work, etc. It is possible to search through the whole of
the database looking for those records with a particular
value or statement in a particular field. For example, if you
wished to know how many accidents involved an injury to
the hand, where protective gloves were not being worn,
you would make a search in the field of “part of the body
injured” and combine this with “gloves worn” in the PPE
section.
Many programs will help in an audit of the health and
safety performance of the organisation, and will perform
calculations and produce a report, with all the appropriate
graphs and diagrams, ready to place on the managing
director’s desk.
• Is the program user-friendly? Can it be used by
computer illiterates? Is it for use by one person, or
on a network and available for many to use? Is the
package flexible? Can we adapt it for our situation?
Is it so general that we don’t need half of it, or is it
lacking some things that are essential to us? Do we
invalidate any guarantee if we make alterations? Can
we have it on trial? Is it installed on site, serviced for
initial problems and provided with a backup service
arrangement? Is there some special concession if
future program improvements are made?
If you get satisfaction on all those points, you should get
some good service from an audit software package.
Production of Reports
Once you have your computer program up and running
you can use it to produce a number of reports, on a regular
basis, to suit your company needs. The reports could look
at the numbers of accidents or incidents, for example,
or the results of an audit. The reports can be produced
in a format to suit the reader. For example, it may be
appropriate to send monthly accident statistics to local
managers and some simple graphical representations of
the numbers, particularly those which correspond to their
area of responsibility. The Board of Directors, however,
may require more in-depth information, especially if there
are high-risk areas within the work situation.
The audit program usually asks a series of questions and
the answers are typed in, or a choice made from a list of
answers. If the questions are answered honestly then the
result will be a good assessment of your situation. It is
important that any program is tailored to exactly fit your
own situation. If your organisation has such a program
then it would be useful for you to have some experience of
using it.
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Monitoring and Measurement Techniques
COMPARISONS OF PERFORMANCE DATA
Previous Performance
It is always useful to compare present performance data
with that obtained over the last few months or last year.
The comparison of performance over time shows the
overall trend and whether performance appears to be
improving or deteriorating. However, you need to look at
a reasonably long period of time as there may be seasonal
fluctuations, for example, which could give a false view of
performance. One way of overcoming fluctuations is to use
the moving average, which shows the trend over time.
Other factors could affect the data, e.g. a reduction in
worker numbers may lead to a reduction in absolute
accident numbers which could be misread as an
improvement in safety performance. To avoid such issues
it is possible to use accident rates which take into account
the numbers of workers working and/or the number of
man-hours worked, etc.
Performance of Similar Organisations/
Industry Sectors
Sometimes it is useful to compare company data against
other organisations or industry sectors that carry out
similar functions, or that deal with similar hazards. In this
way, you can compare the performance of your company
with others (benchmark) to determine the differences
and similarities. Remember that you should check that the
measurable parameters used are the same (it is easy to
manipulate data by using different units of measurement
or criteria). Once you have established that the data is
comparable, it is worth trying to identify whether the
trends are similar. Where there are marked differences,
think about the reasons for these, e.g. geographical
locations, different customer base, different shift patterns,
etc. Some simple analysis may help you to understand your
own data and may give you ideas as to how improvements
can be made.
It can be reassuring to compare data with other companies
or, on the other hand, it can be alarming; whatever the
outcome it is a worthwhile exercise.
© RRC International
National Performance Data
Some performance data is produced by national
enforcement agencies and also by international
organisations (such as the World Health Organisation).
This data can be useful in gauging where you are as
a company, i.e. are you maintaining standards in line
with national or international figures, or are there
improvements to be made? It is easy to become
complacent with respect to health and safety performance,
particularly if your company appears to be continually
improving. By comparing your company results to national
figures, you may become motivated to further that
improvement.
In Element IA2 we considered how to calculate injury rates,
and to analyse and interpret raw data. It is worth revising
that information at this point.
USE OF BENCHMARKING
GLOSSARY
BENCHMARKING
The process of comparing your own practices and
performance measures with organisations that
display excellence and whom you might wish to
emulate.
One tool available for larger organisations (with 250+
employees) was the UK HSE Corporate Health and Safety
Performance Index (CHaSPI) carried out online.
HSE Research Report RR813 Review of CHaSPI concluded
that many users felt that CHaSPI had limited impact due
to levels of awareness and number of users. Greater future
use was envisaged if the benefits of the tool were better
promoted. However, CHaSPI does illustrate the principles
of benchmarking.
MORE…
You can find more information on this
benchmarking tool in RR813 Review of CHaSPI
(HSE) at:
www.hse.gov.uk/research/rrpdf/rr813.pdf
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Monitoring and Measurement Techniques
Potential Benefits of Benchmarking
Benchmarking has a range of potential benefits which
include:
• Allowing employers to measure, compare and
benchmark their health and safety performance.
• Helping external stakeholders, such as insurers,
investors, trade unions and regulators, to assess how
well businesses are meeting their health and safety
responsibilities and managing their risks.
• Demonstrating the organisation’s commitment to
health and safety.
• Providing an indicator of performance.
• Allowing better engagement with stakeholders.
MORE…
You can find more information on performance
indicators at:
Step Change in Safety: Leading performance
indicators – Guidance for effective use (undated):
www.stepchangeinsafety.net/knowledgecentre/
publications/publication.cfm/publicationid/26
Health and Safety Executive: Developing process
safety indicators: A step-by-step guide for chemical
and major hazard industries (HSG254) (Sudbury:
HSE Books, 2006): www.hse.gov.uk/pubns/books/
hsg254.htm.
Institution of Occupational Safety and Health
(IOSH): Reporting performance - guidance on
including health and safety performance in annual
reports: www.iosh.co.uk/~/media/Documents/
Books%20and%20resources/Guidance%20and%20
tools/Reporting_performance.ashx
REVISION QUESTIONS
4. List the main measurement techniques available
for measuring health and safety performance in
the workplace.
5. Explain the difference between an internal and
an external audit.
6. Explain the term “benchmarking”.
(Suggested Answers are at the end.)
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Reviewing Health and Safety Performance
KEY INFORMATION
• The review process uses information from monitoring and audit data to make judgments regarding the
effectiveness of the management system.
• This can then lead to changes in the elements of the system and so continuous improvement.
The review would probably cover:
• Assessment of degree of compliance with set standards.
• Identification of areas where improvements are
required.
• Assessment of specific set objectives.
• Analysis of accident and incident trends.
The safety committee and safety representatives,
supervisors and management, would all be involved in the
review process.
FORMAL AND INFORMAL REVIEWS OF
PERFORMANCE
Review is the process of making judgments regarding
the effectiveness of the occupational health and safety
management system, and then making decisions to remedy
any deficiencies that have been identified. It is a key
element of any quality system.
Review should be a continuous process and should be both
formal and informal at different levels in the organisation.
A formal review will be carried out periodically, e.g.
annually, and may cover the whole site or organisation,
whereas an informal review might be instigated by, for
example, a supervisor who has identified a failure by
workers to adhere to required control measures (e.g. not
wearing PPE).
REVIEW PROCESS
Review is combined with audit procedures. The audit looks
at all aspects of the system - policy, organisation, planning,
implementation and systems for measuring and control.
Reviewing is the process which reacts to the findings of
the performance measuring process. There should be an
instant review in the event of an accident which causes
an injury or loss. We have to learn from mistakes and
be prepared to make changes. For any system of health
and safety which is vital and dynamic, there will have to
be periodic reviews. In many systems it would probably
involve:
• Monthly review of each section.
• Quarterly review of each department.
• Annual review of the organisation.
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Reviewing Health and Safety Performance
TOPIC FOCUS
Inputs to a Review Process
A range of information is used as the basis of the
review, including:
• Internal performance data, e.g. audit, accident, ill
health and incident data, safety climate data.
• Achievement of specific objectives.
• Organisational arrangements, including any
changes.
• External standards and legislation.
• Expectations of stakeholders.
Outputs from a Review Process
The review process leads to specific outputs which
should lead to continuous improvement:
• Specific actions and improvement plans which
meet the SMART criteria.
• New performance targets relating to both active
and reactive measures (e.g. lost-time accidents).
• Reports to stakeholders, e.g. shareholders,
employee groups, regulators.
REVISION QUESTION
7. Which two sources of information does the
review process use?
(Suggested Answer is at the end.)
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Summary
SUMMARY
Purpose of Performance Measurement
Performance measurement serves four purposes:
• It establishes whether the policy and its arrangements have been effectively implemented, including the adequacy
of control measures.
• It provides information for the review process which looks at the effectiveness of the entire health and safety
management system and leads to changes that lead to improvement.
• It enables success to be measured and rewarded.
• It maintains and improves health and safety performance.
When setting objectives, we have to consider performance standards and indicators. Two measuring systems in use
are:
• Active systems, which monitor the achievement of objectives and the extent of compliance with standards
(e.g. monitoring the safety of plant and equipment; compliance with safe systems of work; safe behaviour by
employees).
• Reactive systems, which monitor accidents, ill health, incidents and other evidence of deficient health and safety
performance, such as hazard reports.
Monitoring Systems
Objectives of active monitoring are to check that the health and safety plans have been implemented and to
monitor the extent of compliance with:
• The organisation’s systems and procedures.
• Legislation and technical standards.
Objectives of reactive monitoring are to analyse data relating to:
• Accidents.
• Ill-health situations.
• Other loss-causing events.
• Any other factors which degrade the system.
Accident recording has some value, but is of limited use in relation to assessing future risk. There are problems
with under-reporting of minor accidents. Time off work does not correlate well with the severity of an injury. Also,
if workers are made aware of safety matters, they tend to report more accidents. The picture may then look worse,
when actually the safety culture is improving.
Distinctions between, and applicability of, performance measures are:
• Active means ‘before it happens’, while reactive means ‘after it has happened’.
• Objective means that it can be accurately measured, while subjective means that it depends on someone’s
opinion.
• Qualitative measures are those like reports and commentaries, which although useful are difficult to treat as an
accurate measure, while some kind of score is quantitative.
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Summary
Monitoring and Measurement Techniques
Measurement techniques include:
• Health and safety audits.
• Workplace inspections.
• Safety tours.
• Safety sampling.
• Safety surveys.
The term safety audit is used in several ways. It can be:
• Nothing more than an inspection, safety sampling, or a safety survey - it is best not to use the term ‘audit’ for this
situation.
• A detailed internal investigation of the safety systems and practices of the organisation.
• An external safety audit, carried out by an outside organisation.
Reviewing Health and Safety Performance
Review is combined with audit procedures. The audit looks at all aspects of the system - policy, organisation,
planning, implementation and systems for measuring and control. Reviewing is the process which reacts to the
findings of the performance measuring process. In many systems it would probably involve:
• Monthly review of each section.
• Quarterly review of each department.
• Annual review of the organisation.
The review would probably cover:
• Assessment of degree of compliance with set standards.
• Identification of areas where improvements are required.
• Assessment of specific set objectives.
• Analysis of accident and incident trends.
The safety committee and safety representatives, supervisors and management, would all be involved in the review
process.
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Exam Skills
This is another 10 mark question, but it is split into two sub-questions which have different mark allocations.
This is a format which is quite common in Section A questions.
QUESTION
An advertising campaign was used to promote improvement in safety standards within a particular organisation.
During the period of the campaign the rate of reported accidents significantly increased, and the campaign was
deemed to be a failure.
(a) Suggest, with reasons, why the rate of reported accidents may have been a poor measure of the
campaign’s effectiveness.
(b) Describe four active measures which might have been used to measure the organisation’s health
and safety performance.
(2)
(8)
APPROACHING THE QUESTION
SUGGESTED ANSWER OUTLINE
Remember to:
In part (a) of your answer the Examiner would expect you
to give the reasons why the number of reported accidents
went up.
• Read the question carefully.
• Consider the marks available. Here there are two
parts to the question so you should allocate your time
carefully – 2 to 3 minutes for part (a) and 10 to 12
minutes for part (b).
• Prepare an outline plan:
–– For part (a) it might include:
–– Why? Elaborate on these reasons.
–– For part (b) it might include:
–– List methods and choose four of them.
–– Describe how they would be “active”. (Note
that “active” is sometimes also known as
“proactive”.)
HINTS AND TIPS
Remember to present your answer in two parts, (a)
and (b), and answer the specific questions asked in
the two different sub-questions.
Possible reasons might be:
• Pre-campaign under-reporting - the campaign made
people aware of what they should be reporting;
accidents/incidents may have been happening but
were previously not reported.
• Increased awareness – workers now expecting more
follow-up of issues raised, so will now actually report
them.
• Previous under-reporting possibly due to worker
reluctance because of:
–– Disciplining of those who reported such incidents
on previous occasions.
–– Negative organisational health and safety culture
which discouraged accident reporting.
–– Lack of action by management when accidents
were reported.
In part (b) you need to give four examples of active
techniques which are available to measure an organisation’s
health and safety performance. These could include:
• Consultation – how frequent; its effectiveness;
adherence to procedures.
• Procedures, safe systems of work, risk assessments,
etc. – how many of them; whether they are up to date;
awareness of them; adherence to them; whether or not
in place.
• Training – hours done/delivered/attended; %age
compliance with mandatory courses; refresher courses
completed on time/those overdue; number of “no
shows” on courses.
• Safety audits – number carried out compared to
target number; findings completed compared to those
overdue; issues raised by trends.
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Exam Skills
• Inspections – numbers completed compared to target
numbers; findings completed compared to those
overdue; issues raised by trends.
• Behavioural tours – numbers carried out compared to
target numbers; findings completed compared to those
overdue; issues raised by trends.
• Benchmarking – which department/other organisation
compared with; results.
HINTS AND TIPS
In your part (b) answer do not be tempted to give
more than four examples – you won’t gain any extra
marks by giving five!
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Exam Skills
POSSIBLE ANSWER BY EXAM CANDIDATE
(a) Following the campaign, the number of accidents may have significantly increased because of a number of
factors; these could include that previously very few people were actually aware that they needed to report accidents,
so accidents happened, but weren’t reported – resulting in under-reporting.
It may also have been that the campaign was very successful because it now raised people’s awareness and
expectations of what will be done now you have encouraged people to report accidents on site.
(b)Four active methods of measuring H&S performance of the organisation could entail:
–– Safety tours – these tours could take place on a regular basis and identify good and poor practice; these
practices could then be logged to measure performance by scoring or tracking good and poor practice.
–– Procedures, risk assessments, etc. – measuring the numbers that have been done against numbers required,
checking whether they are in date and being reviewed in line with set frequencies, communicated to staff – by
measuring awareness or understanding of them.
–– Safety surveys – using a set survey and evaluating strengths and weakness and setting strategy for the future
and implementing campaigns and then being able to measure through a survey the effectiveness of this
campaign.
–– Benchmarking – comparing your performance to previous years/months, other departments, sites or
comparable companies (e.g. from national accident statistics published for your particular sector) to measure
your performance in an active manner.
REASONS FOR POOR MARKS ACHIEVED BY CANDIDATES IN EXAM
An exam candidate answering this question would achieve poor marks for:
• Lack of knowledge or understanding of reasons why accident reporting increased.
• Lack of in-depth knowledge or understanding of four examples of active health and safety performance measures.
© RRC International
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IDENTIFYING HAZARDS, ASSESSING AND
EVALUATING RISKS
ELEMENT
4
LEARNING OUTCOMES
On completion of this element, you should
be able to demonstrate understanding
of the content through the application
of knowledge to familiar and unfamiliar
situations and the critical analysis and
evaluation of information presented in
both quantitative and qualitative forms. In
particular you should be able to:

Describe
how to use internal and external sources of
information in the identification of hazards and the
assessment of risk.
Outline a range of hazard identification techniques.

Explain
how to assess and evaluate risk and to
implement a risk assessment programme.
the principles and techniques of failure
Explain
tracing methodologies with the use of calculations.
© RRC International
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Contents
SOURCES OF INFORMATION TO SUPPORT HAZARD IDENTIFICATION AND RISK ASSESSMENT
Accident/Incident and Ill-Health Data and Rates
External Information Sources
Internal Information Sources
Uses and Limitations of Information Sources
Revision Questions
4-3
4-3
4-4
4-4
4-4
4-5
HAZARD IDENTIFICATION TECHNIQUES
Hazard Detection Techniques
Importance of Worker Input
Revision Question
4-6
4-6
4-7
4-7
ASSESSMENT AND EVALUATION OF RISK
Key Steps in a Risk Assessment
Temporary Situations
Types of Risk Assessment
Organisational Arrangements for an Effective Risk Assessment Programme
Acceptability/Tolerability of Risk
Revision Questions
4-8
4-8
4-11
4-11
4-13
4-14
4-15
FAILURE TRACING METHODOLOGIES
A Guide to Basic Probability
Principles and Techniques of Failure Tracing Methods in the Assessment of Risk
Revision Questions
4-16
4-16
4-17
4-29
SUMMARY
4-30
EXAM SKILLS
4-32
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Sources of Information to Support Hazard Identification and
Risk Assessment
KEY INFORMATION
• Accident and ill-health data may be used to calculate incidence, frequency, severity and prevalence rates.
• External information sources include:
–– National governmental enforcement agencies such as the UK’s Health and Safety Executive (HSE), the USA’s
Occupational Safety and Health Administration (OSHA) and Western Australia’s WorkSafe.
–– International bodies such as the European Safety Agency, the International Labour Organisation (ILO) and the
World Health Organisation (WHO).
–– Professional bodies such as the Institution of Occupational Safety and Health (IOSH) and the International
Institute of Risk and Safety Management (IIRSM).
–– Trade unions.
–– Insurance companies.
–– Trade associations.
• Internal information sources include:
–– Injury data.
–– Ill-health data.
–– Property damage.
–– Near-miss information.
–– Maintenance records.
–– Accident, ill-health and near-miss data are often under-reported.
• Trends cannot be established unless large amounts of data are collected over relatively long periods of time.
ACCIDENT/INCIDENT AND ILL-HEALTH
DATA AND RATES
Incidence Rate
Incident data can be used to support hazard identification,
risk assessment and risk factors. Some of the accident data
collected is used to generate the statistics required by
legislation but other uses are to:
Incidence reflects the number of new cases in relation to
the number at risk.
This is calculated from:
Number of work-related injuries × 1,000
Average number of persons employed
• Classify industries according to risk.
• Consider accident trends.
It is a measure of the number of injuries per 1,000
employees and is usually calculated over a period of time,
e.g. a year. It is often applied to discrete events, such as
accidents.
• Consider parts of the body injured - use of protective
clothing.
Frequency Rate
• Classify workplaces.
• Classify occupations.
• Use ‘cause of injury’ to determine hazards in a
workplace.
This can be calculated from:
Number of work-related injuries × 100,000
• Consider where the fault lies.
• Measure the effect of preventative/control measures.
It can sometimes be difficult to obtain and interpret such
information.
Total number of man-hours worked
It is a measure of the number of accidents per 100,000
hours worked.
Severity Rate
This is:
Accident and Disease Ratios
In making comparisons between various industries, or
between work areas in the same factory, it is useful to
consider the commonly used accident and disease rates.
You will remember these from Element IA2.
© RRC International
Total number of days lost × 1,000
Total number of man-hours worked
It is a measure of the average number of days lost per
1,000 hours worked.
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Sources of Information to Support Hazard Identification and
Risk Assessment
Prevalence Rate
INTERNAL INFORMATION SOURCES
Prevalence is a term often used to describe ill health
in terms of the proportion of persons who have the
prescribed ill-health condition at a particular time.
TOPIC FOCUS
Internal information is the most relevant data for an
organisation, but other sources will be needed for
comparisons, unless the organisation is large enough
to give statistical significance.
It can be calculated from:
The total number of cases of ill health in the population × 100
Total number of persons at risk
This calculation will give the percentage of the population
with the disease.
There should be a source of accident and ill-health
data, as well as near-miss information, within the
company.
EXTERNAL INFORMATION SOURCES
• Accident reports will be the most obvious
source. It is important that the information
recorded is adequate for risk assessments. We
need to be able to investigate factors which
contributed to the accident which means making
a clear distinction between “cause of accident”
and “cause of injury”.
TOPIC FOCUS
External information sources include:
• National governmental enforcement agencies
such as the UK’s HSE (www.hse.gov.uk/), the
USA’s OSHA (www.osha.gov/), and Western
Australia’s WorkSafe (www.docep.wa.gov.au/
WorkSafe/). These all produce legal and best
practice guidance and statistics. Even if you
are not under their regulatory control, their
guidance can still be a valuable source of advice,
especially where little or none exists in your
region.
• International bodies such as the European Safety
Agency (osha.europa.eu/); the International
Labour Organisation and their “safework”
site (www.ilo.org/); and the World Health
Organisation (www.who.int).
• Professional bodies such as IOSH (www.iosh.
co.uk/) and IIRSM (www.iirsm.org/).
• Trade unions, a number of whom produce
information on safety and health matters. The
trade union interest here may be in making
members aware of possible compensation areas.
• Insurance companies, who set the levels of
premiums and need data to calculate the
probable risks of any venture. The average
risks involved in most activities can be found
in insurance tables. Since the risk manager is
involved in managing risks, these tables will be
extremely useful, although getting hold of them
may not be so easy.
• Absence records may be another indication of
problems. Health problems may not always be
reported, so conditions which are made worse by
the work situation, rather than being caused by
it, are not so easy to spot.
• Maintenance records will usually show damage
incidents.
USES AND LIMITATIONS OF INFORMATION
SOURCES
Internal information is obviously very relevant to risk
assessments. However, the absence of accidents is not a
very good indication that all is well. Can you think why this
is so?
Accidents should be rare occurrences. Quite often there
is a large element of chance involved in the severity of
an accident. Near misses, which are usually a much larger
figure, are a better indicator of risk.
Care must be taken when using external sources of
information. The numbers are larger, and any statistics are
based on a larger sample, so are statistically more relevant.
However, the type of industry covered may be much wider
than your own situation. In the case of a very specialised
situation this may be the only indication of risk available.
Different sources use a different multiplier when working
out accident frequency rates, etc. so care needs to be
taken when making comparisons.
• Trade associations.
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Sources of Information to Support Hazard Identification and
Risk Assessment
When comparing data between organisations it is
important to make sure that they have the same terms
of reference. For example, when comparing Lost-Time
Accident (LTA) incidence rates between two organisations
(based on numbers of employees), note the following:
• The two organisations may use different definitions
for a LTA (many companies use “more than 1 day
lost” for internal reporting of LTA, whereas some
enforcement agencies use “more than 3 days lost” as
their standard).
• There is no indication of injury severity.
• The figures may be for workers only and so may be
misleading for an organisation that makes wide use of
contractors.
• The figures may not take full account of overtime or
part-time workers (they may not adjust the numbers of
workers to ‘full-time equivalents’).
• Culture differences - one organisation may have a
culture where they take time off even after a very
minor injury; another organisation might have a very
strong ‘back to work’ culture where an injured worker
might be brought back to work on restricted, or ‘light’
duties, in order to avoid recording a lost-time accident.
• There may be different risk levels between
organisations due, for example, to the nature of the
work, premises, equipment, etc.
• There may be different risk management arrangements
in place relating, for example, to standards of risk
assessment, training requirements and standards of
control.
REVISION QUESTIONS
1. What uses might we have for accident and illhealth data?
2. What internal information can organisations use
to help in the assessment of risk?
3. Explain the difference between “incidence” and
“prevalence” when referring to accident or illhealth statistics.
(Suggested Answers are at the end.)
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Unit IA – Element IA4: Identifying Hazards, Assessing and Evaluating Risks
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Hazard Identification Techniques
KEY INFORMATION
Hazards may be identified using:
• Observation.
• Task analysis.
• Checklists.
• Incidents and near misses.
• Failure tracing techniques.
Task Analysis
Task analysis is used to analyse all aspects of a task
(including safety), often with the intention of improving
efficiency. A job can also be analysed with the emphasis on
safety or hazards.
The assessor divides the task into a number of steps,
considering each step separately. The results of this analysis
can be used to correct existing problems and to improve,
among other things:
• Safe working methods, working instructions, worker
protection, safety rules, emergency procedures,
serviceability of machinery and plant.
Detection of hazards
HAZARD DETECTION TECHNIQUES
Before risk can effectively be managed, it is important to
identify any hazards in the workplace; the following are
some techniques that can be used.
Observation
Many hazard identification techniques rely on observation
by the assessor(s) and are dependent on the experience
and knowledge of the assessor.
The analyst should observe the work being done, including
work being carried out by groups of operators, looking for:
• Actual and potential hazards - by observation and
questioning.
• Less obvious ‘invisible’ hazards - such as health dangers
from fumes, gases, noise, lighting and dangerous
substances, etc.
• Behavioural aspects - rules and precautions for
controlling any hazard or risk should be supplied by the
operator, his/her supervisor or a specialist, but are they
being followed?
• Reporting of hazards, provision of information.
• Layout of work areas.
Checklists
To ensure a consistent and comprehensive approach to
checking all the safety elements to be covered during
an inspection, a checklist or inspection form is usually
developed that covers the key issues. Checklists should
also be structured to provide a coherent approach to the
inspection process. This helps in the monitoring of the
inspection process and analysis of the results, as well as
simplifying the task of carrying out the inspection itself.
Checklists do have some limitations in that although they
prompt the assessor when looking for hazards, any hazard
not identified in the list, is less likely to be noticed.
One helpful method of structuring a checklist is by using
the “4 Ps”, as promoted by the UK Health and Safety
Executive (HSE):
• Premises, including:
–– Access/escape.
–– Housekeeping.
–– Working environment.
• Plant and substances, including:
–– Machinery guarding.
–– Local exhaust ventilation.
–– Use/storage/separation of materials/chemicals.
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Hazard Identification Techniques
• Procedures, including:
–– Permits-to-work.
–– Use of personal protective equipment.
–– Procedures followed.
• People, including:
–– Health surveillance.
–– People’s behaviour.
–– Appropriate authorised person.
(Note that the examples given are purely for illustration
and are not intended to be a definitive list.)
While checklists are often included in safety procedures
and manuals, do not feel that they cannot be changed
and adapted. In particular, in terms of maintenance and
safety inspections, the list should not act as a constraint
on the inspector(s) identifying other potential problems
or hazards. Checklists should be reviewed regularly to take
account of recent or proposed developments in health and
safety issues in the particular workplace.
Incident Reports
These represent reactive, but nonetheless useful, data.
Reports can arise from external notification requirements
under national legislation (discussed in Element IA2), or
from internal reporting of all loss and near-miss events.
Certain accidents and occupational ill-health incidents may
be reported to, and analysed by, government regulators
or enforcement agencies. In such cases, annual reports
are usually published giving detailed figures of reported
accidents ‘analysed by cause’. These are useful when
comparing differing sectors of industry.
IMPORTANCE OF WORKER INPUT
Rather than relying on one individual to undertake hazard
identification, the team approach to risk assessment
involves workers who have relevant experience and
knowledge of the process or activity being considered,
as they are likely to have the best understanding of the
hazards.
Can you think of any other reasons why workers should be
involved?
Involving workers also increases the “ownership” of
the assessment as, having contributed to the exercise,
an individual is more likely to appreciate the need for
compliance with the control measures identified.
Each company should maintain its own records, not just of
‘notifiable’ accidents and ill health, but of all accidents that
have taken place. In this way, any trends, or particular areas
that show significant changes, can be investigated at the
earliest opportunity. The reports will also be a useful tool
when carrying out risk assessments.
Failure Tracing Techniques
The techniques we have described are usually more than
adequate for most risk assessments. In more complex
systems it may be necessary to use more structured
methods to identify hazards. One powerful technique is
called a Hazard and Operability Study (or HAZOP).
This breaks down a system, such as a chemical process,
into different sections and then systematically asks
what could go wrong in that section, what would be the
consequences, and what measures could be introduced to
reduce the likelihood of the failure occurring or, if it does
fail, might mitigate the consequences. We will look at this
and other techniques later in this element.
REVISION QUESTION
4. Giving two examples for each, identify the “4Ps”
promoted by the UK’s HSE when preparing a
checklist for inspections.
(Suggested Answer is at the end.)
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Assessment and Evaluation of Risk
KEY INFORMATION
• The key steps in a risk assessment are:
–– Hazard identification.
–– Identification of who is at risk.
–– Estimation, evaluation of risk and identification of precautions.
–– Recording of significant findings and implementation.
–– Reviewing the assessment.
• Risk assessments may be qualitative, semi-quantitative or quantitative.
• The risk assessment process should be reflected in a policy, organising, planning and implementing, monitoring
and review.
• Risks may be evaluated as being acceptable, unacceptable or tolerable.
KEY STEPS IN A RISK ASSESSMENT
Decide Who Might be Harmed and How
According to the UK’s HSE publication Risk assessment
It is important to identify the different categories of
persons who are exposed to each hazard, because this will
influence the choice of control measures that could be
adopted to reduce the risk. For example, control measures
such as training could be used to protect workers, but
would not be practicable for protecting others, such as
members of the public.
– A brief guide to controlling risks in the workplace
(INDG163):
‘a risk assessment is not about creating huge amounts
of paperwork, but rather about identifying sensible
measures to control the risks in your workplace.’
For the majority of work activities the five step approach is
recommended:
The categories might include:
• Step 1: Identify the hazards.
• Workers carrying out a task, e.g. operating a lathe.
• Step 2: Decide who might be harmed and how.
• Other workers working nearby who might be affected.
• Step 3: Evaluate the risks and decide on precautions.
• Visitors/members of the public.
• Step 4: Record your findings and implement them.
• Maintenance staff.
• Step 5: Review your assessment and update if
necessary.
• New/young workers.
Implicit within Step 3 of risk evaluation is the need to
estimate the magnitude of the risk so here we will consider
Step 3 as risk estimation, evaluation and deciding on
precautions.
• Persons who work for another employer in a shared
workplace.
Identify the Hazards
This is a crucial step in any risk assessment; we have already
discussed the techniques that can be used.
• Persons with a disability.
For each category you need to identify how they might be
harmed. For example, for workers operating a lathe, loose
clothing could become entangled in the rotating spindle,
and other employees working nearby might be struck by
swarf.
Risk Estimation, Evaluation and
Precautions
Risk is the chance, high or low, that somebody could be
harmed by these and other hazards, together with an
indication of how serious the harm could be.
It is important that you understand the difference between
risk estimation and evaluation.
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Assessment and Evaluation of Risk
Of course, merely encountering a hazard does not mean
we will be harmed. Some people will see the hazard and
avoid it deliberately and others will walk over it without
being tripped up. In other words, a specific set of events
must occur before a trip will occur, namely:
GLOSSARY
RISK ESTIMATION
Risk estimation is determining the magnitude of
the size of the risk. This may range from being
a relatively crude estimation, e.g. high, medium
or low, to a more accurate estimation based
on data. “Estimation” is used because risk deals
with uncertainty and even the most detailed risk
assessments have to make a number of assumptions.
• Not noticing the hazard and taking avoiding action.
• Placing a foot into the tear such that the person can no
longer maintain his or her balance.
The consequence is the outcome from the adverse
incident occurrence. From most such incidents there is not
just one possible outcome, but a whole range of them. For
example, with our torn carpet, one individual might trip on
the tear, recover their balance and suffer no harm at all. At
the other extreme, someone else may trip, hit their head
and die. In practice we have to use our judgment to decide
the most likely outcome, probably in this case just a bruise.
However, if the same incident occurred in a care home
where most of the residents were elderly and frail, then the
most likely consequence may well be a fracture.
EVALUATION
Evaluation is the decision-making process
whereby we decide, on the basis of the risk we
have estimated, as to whether it is acceptable or
otherwise.
Factors Affecting Probability and Severity
of Risk
Risk Evaluation
The magnitude of a risk associated with an incident is
determined by two factors:
Having estimated the magnitude of the risk, we then have
to decide if the existing control measures are adequate,
or whether additional/different ones are necessary.
According to the HSE publication Risk assessment – A brief
guide to controlling risks in the workplace (INDG163),
the easiest way of evaluating the risk is to compare
your practices with recognised guidance. This is more
than adequate for most assessments. However, as safety
practitioners who may encounter non-routine or more
complex risks, having made an informed estimation of the
magnitude of the risk, we can use the information to help
us decide what action, if any, is necessary.
• The likelihood or probability of the event occurring,
and
• The consequence or harm realised if the event takes
place.
This is usually expressed as:
Risk = Likelihood (or Probability) ×
Consequence (or Harm)
We now need to look at the factors that affect both the
likelihood and the consequence.
The likelihood of an adverse event occurring is affected by
two factors:
• Degree of exposure to the hazard and, once exposed
to the hazard,
We will consider the concept of risk acceptability and
tolerability later in this element.
Risk Control Standards
Having evaluated the risk and established whether or not
it is acceptable, you have to ensure that the controls meet
minimum standards. Such standards may be defined in
legislation, codes of practice and relevant guidance.
• The likelihood that harm will occur.
Let’s look at an example.
Consider a torn carpet in an office and the risks it creates.
Before somebody could possibly trip on the carpet, they
have to walk in the vicinity of the carpet, so the degree
of exposure to the hazard is a key factor. If the carpet
is situated in the centre of a main walkway then the
likelihood of it causing an accident is much greater than
if it is in a corner of a little-used store room. Similarly, the
hazard from crossing a road will create a greater probability
of harm if we cross the road several times a day, rather
than if we cross it only several times a year.
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Assessment and Evaluation of Risk
Formulation and Prioritisation of Actions
When deciding on what action to take you should always
follow the hierarchy of controls:
• Elimination - can I remove the hazard altogether? If
not, how can I control the risks so that harm is unlikely?
• Substitute the hazard - try a less risky option (e.g.
switch to using a less hazardous substance).
• Contain the risk - prevent access to the hazard (e.g. by
guarding).
• Reduce exposure to the hazard - reduce the number
of persons exposed to the hazard and/or reduce the
duration of exposure.
• Personal protective equipment - provide protection
for each individual at risk.
TOPIC FOCUS
Suitable and sufficient
This term is employed in UK legislation (Regulation
3, Management of Health and Safety at Work
Regulations 1999), to ensure that the risk
assessment process is comprehensive. Consequently
the risk assessment should:
• Identify the significant risks arising from, or
in connection with, the work. The detail in an
assessment should be proportionate to the risk,
so if the hazards are simple, the assessment and
record can be straightforward based on informed
judgment and reference to relevant guidance.
In many intermediate cases the risk assessment
will need to be more detailed and may need
access to specialist guidance and the use of
analytical techniques, e.g. a noise meter to
measure noise levels.
• Skill/supervision - rely on the competence of the
individual.
• Welfare arrangements - provide washing facilities to
remove contamination and first aid facilities.
Invariably, combinations of control are applied, rather than
relying on one alone. Just because a measure is near the
bottom of the hierarchy does not mean it is not important
(e.g. first aid) - it just means that an employer should not
rely exclusively on it and must consider measures higher up
the hierarchy.
If we have made an evaluation of the risk we should then
be able to prioritise the necessary actions in terms of risks
that need immediate attention, e.g. because of serious
non-compliance, and those that may be dealt with in the
short or even long term when resources become available.
These actions may reflect going beyond the minimum legal
standard and be best practice.
Recording Requirements
Clearly, it is good practice to record the details of risk
assessment.
The significant findings should include:
• A record of the preventive and protective measures in
place to control the risks.
• What further action, if any, needs to be taken to reduce
risk sufficiently.
In many cases, employers (and the self-employed) will
also need to record sufficient detail of the assessment
itself, so that they can demonstrate that they have carried
out a suitable and sufficient assessment. This record of
the significant findings will also form a basis for a future
revision of the assessment.
4-10
The most hazardous sites will require the
most sophisticated risk assessments, especially
where there are complex or unusual processes.
For example, if a site stores bulk amounts of
hazardous substances then the risk assessment
may require the use of techniques such as
quantified risk assessment (see later in the
element).
Risk assessments must also consider all those
who might be affected by the activities, whether
they are workers or others, such as members
of the public. For example, the assessment
produced by a railway company will need to
consider the hazards and risks which arise from
the trains that not only affect workers but also
contractors and the public.
• Employers and the self-employed are required to
take reasonable steps to help themselves identify
risks by accessing appropriate legislation and
guidance, manufacturers’ instructions, or seeking
competent advice.
• The risk assessment should indicate the period
of time for which it is likely to be valid. This
will allow management to know when shortterm control measures should be reviewed and
modified.
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Assessment and Evaluation of Risk
Qualitative Assessments
TEMPORARY SITUATIONS
For workplaces where the nature of the work may change
frequently (such as contract maintenance work), or the
workplace itself changes (such as a construction site), the
risk assessment needs to be more dynamic in order to
accommodate these changing situations. In these situations
it may be necessary to concentrate more on a broad range
of foreseeable risks and develop a range of appropriate
control options for these rather than try to document rigid
control measures for a temporary and changing workplace.
For this approach to be effective in a temporary situation,
detailed planning and worker training in dealing with the
significant risks is essential.
TYPES OF RISK ASSESSMENT
Before we continue, let’s remind ourselves of the
definitions of the following two terms:
• Quantitative - a measurement of magnitude is
involved, e.g. there were four fatalities due to falls
from height over a 12-month period at Business X; the
airborne concentration of formaldehyde in a workplace
was measured as 13ppm.
• Qualitative - no actual measurement is used. It
involves describing the qualities, e.g. the airborne
concentration was high or serious; the injury sustained
was minor.
There are conceptually two basic categories of risk
assessment: qualitative and quantitative. In practice there
is also a third category which uses numbers to indicate
rank order, called semi-quantitative. Quantitative risk
assessment uses more rigorous techniques in an attempt to
quantify the magnitude of the risk. Even in the high hazard
industries (such as nuclear and chemical) most of the
assessments are not quantitative. However, they are often
used to satisfy a regulator that very unlikely events which, if
they occurred, would have serious consequences not only
to the organisation but also to the public (such as loss of
containment of radioactive material in a nuclear facility)
have been assessed. All risk assessments involve at least
some element of subjectivity or judgment.
GLOSSARY
QUALITATIVE RISK ASSESSMENT
“A qualitative risk assessment is the comprehensive
identification and description of hazards from a
specified activity, to people or the environment.
The range of possible events may be represented by
broad categories, with classification of the likelihood
and consequences, to facilitate their comparison and
the identification of priorities.”
Qualitative risk assessments are based entirely on
judgment, opinion and experience including approved
guidance, rather than on measurements. They use
technology-based criteria to establish if you have done
enough to control risks, i.e. “If I use this standard control
measure I’m pretty sure the risk will be adequately
controlled”. They allow you to easily prioritise risks for
further action, but while they enable risks to be ranked
against other risks, they do not objectively estimate risks
and so do not allow direct comparisons with external
estimates.
A qualitative risk assessment is carried out by the risk
assessor(s) making qualitative judgments with respect
to the likelihood and consequence associated with a
particular loss event. This judgment may be made through
observation and discussion with workers, as well as looking
at other information, e.g. accident records. There are
various ways in which likelihood and consequence could be
categorised; the following is a simple example.
Example
Consider our torn carpet example again. There are a
number of possible outcomes should someone trip on it;
the severity categories might be:
• Minor - minor injury or illness with no significant lost
time, such as a slight cut or bruise.
• Lost time - more serious injury causing short-term
incapacity from work or illness causing short-term ill
health, e.g. broken limb.
• Major - fatality or injury/illness causing long-term
disability.
We use our experience to qualitatively judge the most
likely outcome. We need to be sensible here otherwise
we will end up with the worst possible consequence always
being death (or even multiple deaths) and the ability to
prioritise remedial action is defeated as a result.
In this example, the likely outcome could be that someone
would be badly bruised with no significant lost time, and
therefore “Minor” would be chosen.
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Assessment and Evaluation of Risk
The likelihood of someone tripping over the carpet could
be categorised by one of the following terms:
Here is simple 3 x 3 matrix:
Matrix ranking risk in terms of likelihood and consequence
• Very likely.
• Likely.
L
i
k
e
l
i
h
o
o
d
• Unlikely.
In this example we might judge that the likelihood of
exposure to the hazard (coming into contact with the torn
carpet) and subsequently tripping might be “Likely”.
Think of our earlier equation for risk magnitude:
Risk = Likelihood (or Frequency) x Consequence (or Harm
or Severity)
It follows then, that, although no numbers are being
used, it is easy to see that the risk of someone injuring
themselves on the torn carpet is moderate. For this reason,
remedial action must be carried out to minimise the risk
which in the short term might involve using carpet tape to
join the two ends. Where there are a number of hazards
that have been assessed in a similar way, it is possible to
prioritise the remedial action so that the ones which pose
the greatest risk are resolved first.
Clearly each organisation would need to come up with
their own categories which reflect the types of injury that
may occur along with their likelihood frequency.
If the descriptors “Minor”, “Lost time”, “Major” are
replaced arbitrarily with ‘1’, ‘2’ and ‘3’, respectively, this
is still a qualitative risk assessment since there is still no
quantitative basis for the choice - just a switch of numbers
for words. So, don’t think that the mere presence of
numbers somehow converts it into a more thorough
quantitative assessment.
6
9
M=2
2
4
6
L=1
1
2
3
Medium = 2
High = 3
Consequence
The likelihood and consequence are each characterised
as low, medium or high and are assigned a number 1, 2 or
3 respectively. The risk is determined by calculating the
product of the likelihood and the consequence, so risks
range from 1 (low likelihood and low consequence) to 9
(high likelihood and high consequence).
The key point about such matrices is that they are used to
rank risks, i.e. put them in order. They have no meaning in
terms of their relative sizes so it cannot be assumed that a
risk value of 9 is nine times the size of a risk rating of 1.
Quantitative Risk Assessment
GLOSSARY
QUANTITATIVE RISK ASSESSMENT
“A quantitative risk assessment is the application of
methodology to produce a numerical representation
of the frequency and extent of a specified level
of exposure or harm, to specified people or the
environment, from a specified activity. This will
facilitate comparison of the results with specified
criteria.”
In many risk assessments where the hazards are not
few and simple, nor numerous and complex, it may be
necessary to use some semi-quantitative assessments in
addition to the simple qualitative assessments.
Semi-quantitative risk assessments may also use a
simple matrix to combine estimates of likelihood and
consequence in order to place risks in rank order.
3
Low = 1
Semi-Quantitative
This may involve measuring the exposure of a worker to a
hazardous substance or noise which can then be used to
assess whether the risks to the workers are acceptable or
not.
H=3
Quantitative risk assessments attempt to calculate
probabilities or frequencies of specific event scenarios. This
is sometimes mandated by legislation, so that the results
can be compared with criteria on what is considered an
acceptable, or a tolerable risk. They may use advanced
simulation or modelling techniques to investigate possible
accidents, and will utilise plant component reliability data.
They are sometimes referred to as QRA or Probabilistic
Risk Analysis (PRA).
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Assessment and Evaluation of Risk
The degree of quantification used is variable. This type of
risk assessment typically uses advanced tools such as fault
tree analysis and event tree analysis (see later). It relies
heavily on having suitable data to calculate the probability
or frequency of a defined event.
QRAs are evidence-based (i.e. use ‘hard’ data) to be
as objective as possible. It may not be possible to fully
quantify risks - especially for infrequent events. Despite
the name, QRAs invariably involve some subjectivity; this
is because some broad assumptions may have to be made,
e.g. in the application of human reliability assessment. This
approach is used for safety cases to establish that the risks
have been fully identified, and to justify that enough has
been done to reduce the risk to the lowest level reasonably
practicable.
QRA is used in high-hazard chemical and nuclear
installations and in the offshore oil industry for specific
risk scenarios. Such risk assessments are included as part of
their safety report requirements. Quantitative methods are
also used in setting Occupational Exposure Limits (OELs)
for airborne contaminants.
For major hazard sites, such as large chemical installations,
numerical estimates of the probability or frequency of
plant failure may be calculated. This is at its most valid
when it involves use of component reliability data, simply
because the data is available (or can be measured) and is
often based on a large sample size and so is statistically
valid. The results of particular failure scenarios would
then be considered, in terms of the different possible
consequences, perhaps using fault trees and event trees
(which may use component, structural, system and/
or human reliability data). Consequence itself is not
usually quantified as such. Rather, many failure scenarios
(perhaps several hundred), all with different consequences
are modelled, and the probability or frequency of each
scenario actually developing is calculated. An example
would be the failure of a chlorine storage vessel in a
particular way with dispersion modelling of several
different release patterns for a toxic gas cloud. In such
cases, the likelihood of harm resulting from all the different
potential causes of failure, has to be rolled up into a single
estimate of the risk from that installation. We will consider
some of these points in more detail when we look at
failure- tracing methods later in this element.
© RRC International
ORGANISATIONAL ARRANGEMENTS
FOR AN EFFECTIVE RISK ASSESSMENT
PROGRAMME
As risk assessment is a fundamental component of a health
and safety management system, it is important that the
process of risk assessment is effectively managed. Earlier
in the course we looked at what constitutes an effective
health and safety management system; it is sensible to use
the elements of a health and safety management system to
manage risk assessment.
Plan
• Where you are now and where you need to be.
• What you want to achieve, who will be responsible for
what, how you will achieve your aims, and how you will
measure your success.
• Write down this policy and your plan to deliver it.
• Decide how you will measure performance, looking
for leading as well as lagging indicators (active and
reactive).
• Remember to plan for changes and identify any specific
legal requirements that apply.
Do
• Identify your risk profile.
–– Assess the risks, identify what could cause harm
in the workplace, who it could harm and how, and
what you will do to manage the risk.
–– Decide what the priorities are and identify the
biggest risks.
• Organise your activities to deliver your plan. In
particular, aim to:
–– Involve workers and communicate, so that
everyone is clear on what is needed and can discuss
issues – develop positive attitudes and behaviours.
–– Provide adequate resources, including competent
advice where needed.
• Implement your plan.
–– Decide on the preventive and protective measures
needed and put them in place.
–– Provide the right tools and equipment to do the job
and keep them maintained.
–– Train and instruct, to ensure everyone is competent
to carry out their work.
–– Supervise to make sure that arrangements are
followed.
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Assessment and Evaluation of Risk
–– Make sure that your plan has been implemented.
–– Assess how well the risks are being controlled and if
you are achieving your aims.
• Investigate the causes of accidents, incidents or near
misses.
Act
• Review your performance.
–– Learn from accidents and incidents, ill-health data,
errors and relevant experience, including from
other organisations.
–– Revisit plans, policy documents and risk
assessments to see if they need updating.
• Take action on lessons learned, including from audit
and inspection reports.
(Based on original source HSG65 Managing for Health and
Safety, HSE, 2013 (www.hse.gov.uk/pubns/priced/hsg65.
pdf))
ACCEPTABILITY/TOLERABILITY OF RISK
There are criteria by which a society decides which risks it
is prepared to expect workers and members of the public
to live with, and those it is not. In the UK the criteria are
set out in the HSE document Reducing Risks, Protecting
People (R2P2) in which, broadly speaking, the risks are
classified into three categories:
• Acceptable - no further action required. These risks
would be considered by most to be insignificant or
trivial and adequately controlled. They are of inherently
low risk, or can be readily controlled to a low level.
• Unacceptable - certain risks that cannot be justified
(except in extraordinary circumstances), despite
any benefits they might bring. Here it is possible to
distinguish between those activities that those at work
are expected to endure, and those that individuals are
permitted to engage in through their own free choice,
e.g. certain dangerous sports/pastimes.
• Tolerable - risks that fall between the acceptable and
unacceptable. Tolerability does not mean acceptable,
but means that society is prepared to endure such risks
because of the benefits they give, and because further
risk reduction is grossly out of proportion in terms of
time, cost, etc. In other words, to make any significant
risk reduction would require such great cost that it
would be out of all proportion to the benefit achieved.
When we discuss benefits we mean:
–– Employment.
–– Lower costs of production.
–– Convenience to the public.
–– Maintenance of a social infrastructure, e.g. supply
of food or production of electricity.
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Increasing individual risk and societal concerns
• Measure your performance.
The terms acceptable, unacceptable and tolerable are best
illustrated by the following figure:
Unacceptable
Tolerable
ALARP region
Acceptable
Tolerability of risk
You can see that the risks that fall into the tolerable
region are described as being “As Low As is Reasonably
Practicable”, often referred to as ALARP.
These are risks that society is prepared to endure on the
following assumptions:
• They are properly assessed to determine adequate
control measures.
• The residual risk (after the implementation of control
measures) is not unduly high.
• The risks are periodically reviewed to ensure they
remain ALARP.
How, then, are tolerability limits defined?
Increasing individual risk and societal concerns
Check
Unacceptable
Tolerable
1 in 1,000
per person/yr
(employee)
1 in 10,000
per person/yr
(public)
ALARP region
1 in 1m
per person/yr
Acceptable
Unacceptable/tolerable/acceptable boundary limits
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Assessment and Evaluation of Risk
• Boundary Between Acceptable and Tolerable
The UK’s HSE believes an individual risk of death of
one in 1 million per year, or less for both workers and
members of the public, is broadly acceptable. This risk
is very low; indeed using gas or electricity, or travelling
by air poses a much greater risk.
• Boundary Between Tolerable and Unacceptable
Here there is a distinction between workers and the
public.
–– For workers, an individual risk of death of one in
1000 per year represents the dividing line between
what is tolerable for an individual for any large
part of their working life and what is unacceptable
(apart from exceptional groups).
–– For members of the public who have risks imposed
on them who live, for example, next to a major
accident hazard, the figure is an individual risk
of death of one in 10,000 per year, i.e. ten times
less risk. This figure equates approximately to the
individual risk of death per year as a result of a road
traffic accident.
MORE…
You can access the HSE publication Reducing risks,
protecting people (R2P2) at:
www.hse.gov.uk/
REVISION QUESTIONS
5. What are the characteristics of a “suitable and
sufficient” risk assessment?
6. What is a tolerable risk?
(Suggested Answers are at the end.)
© RRC International
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Failure Tracing Methodologies
KEY INFORMATION
Failure tracing methods are structured techniques to assist in hazard identification and risk assessment. They include:
• Hazard and operability studies - identify hazards in a system and their effect on the system.
• Fault tree analysis - identifies the necessary events and how they combine to lead to a loss event called the Top
Event.
• Event tree analysis - used to identify the possible consequences from an event and the influence of controls.
A GUIDE TO BASIC PROBABILITY
To understand the advanced risk assessment techniques
that involve quantified risk assessment you need to
understand the basic principles of probability.
Probability of a Single Event Occurring
Probability relates to the chance of an event occurring and
in numerical terms can only have a value between 0 and 1:
• 0 means there is no chance of it happening, i.e. it is
impossible.
• 1 means it is certain to happen.
Suppose we toss a coin.
There are only two possible outcomes, namely Heads or
Tails.
• So, the probability of getting Heads, i.e. ½, or, 0.5.
• The probability of getting Tails is also ½, or, 0.5.
You will notice that given that there are only two possible
outcomes, the sum of the two probabilities equals one, i.e.
Probability of Heads + Probability of Tails = 0.5 +0.5 = 1.
There are four outcomes but only one matches “Heads
and then Heads”; the probability is therefore ¼ = 0.25.
The probability is simply the product of each of the two
events, i.e. ½ × ½ = ¼ =0.25.
So if we wanted to know what the probability is of
obtaining three sixes if we threw three separate dice, it
would be:
1/6 × 1/6 × 1/6 = 1/216 = 0.0047, which is not very
likely!
So to calculate the probability of two or more independent
events occurring, we multiply the probabilities.
Incidentally, the probability of winning the Lotto, i.e.
selecting all six numbers, is 1 in 14,000,000, which is an
extremely remote event! Yet, of course, as millions of
people play every week there is often a winner.
Suppose we now wanted to know what the probability is
of getting a 1 OR a 6 if we threw a dice.
Well the possible outcomes are, of course, 1, 2, 3, 4, 5 and
6. Of these six possibilities two meet our requirement of 1
or 6, i.e. 2 out of 6 = 2/6 (or 0.33).
Similarly, if we threw a six-sided dice, the probability it
would land showing a six would be 1/6 = 0.167.
• The probability of getting a 1 is 1/6.
Probability of Multiple Events Occurring
So the probability of getting a 1 OR a 6 is 1/6 + 1/6 =
1/3.
Suppose we now toss a coin twice. What is the probability
that on both occasions it will show Heads?
Here are all the possible outcomes:
• Heads and then Heads.
• Heads and then Tails.
• The probability of getting a 6 is also 1/6.
In other words, when we want to know the probability of
one event or another, we ADD the probabilities of the two
separate events.
Understanding these principles will be very useful to you
when we look at Fault Tree Analysis.
• Tails and then Heads.
• Tails and then Tails.
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Failure Tracing Methodologies
Probability and Frequency
The studies are carried out by a multidisciplinary team,
usually made up of four to seven people. Members
typically include:
In risk assessment we sometimes refer to the probability
of an event and sometimes to the frequency of an event.
What is the difference?
• Probability is the chance something will happen. So if
the probability of tripping over a torn carpet happened
to be 1 in a 1000, then this means that if 1000 people
walked over the tear, on average, one would trip. How
long this would take would depend how long it takes
1000 people to encounter the tear. If the tear was in a
busy walkway, it might be only a matter of a few hours
or less; if it was in a room that was hardly used, it might
take many years. So exposure to the hazard is very
important.
• Frequency takes account of the exposure. So if we say
the event will happen on average once every 10 years,
we say its frequency is 1/10 or 0.1y-1.
We cannot combine frequencies, i.e. add or multiply
them in the same way that we can probabilities, but we
can multiply a frequency with a probability.
Consider an event which has a probability of harm of
1 in 100, i.e. 0.01, and we know the event occurs 300
times a year; the frequency of the harm will be:
• Study Leader - should not be closely involved with the
project but should have good experience of HAZOP
and can keep the team focused.
• Recorder - documents the proceedings.
• Designer - explains how the system should work.
• A user of the system, such as a production manager.
Others who may contribute include:
• Maintenance engineer.
• Software specialist.
• Safety expert.
• Instrument engineer.
The team have a diagram that represents the system,
showing each of the components of the system and how
they are related. In the case of a chemical process plant this
would be a pipeline and instrumentation diagram.
The steps involved in a HAZOP are:
• Divide the system into parts (sometimes called nodes).
In the case of a chemical process plant this might be a
pipeline between a storage vessel and a reactor.
0.01 (probability of harm) x 300 (frequency of
occurrence per year) = 3 harmful events a year.
• For each part define the design intention, i.e. what is
meant to occur when it is operating normally.
PRINCIPLES AND TECHNIQUES OF FAILURE
TRACING METHODS IN THE ASSESSMENT
OF RISK
Failure tracing methods may be used in more detailed
risk assessments. They are unnecessary in most cases,
but provide a systematic methodology for identification
of hazards and, in some cases, calculation of failure
probabilities, for more complex cases; they are used
extensively in, for example, quantified risk assessment.
They can be used qualitatively and some quantitatively as
well. Some can be used to model incidents and so can be
used in accident investigation.
Hazard and Operability Studies (HAZOPs)
The HAZOP method is designed for dealing with relatively
complex systems, such as large chemical plants or a nuclear
power station, where a deviation from what is expected
in one component of the system may have serious
consequences for other parts of the system The principles
can be used in simpler situations, but a full HAZOP will not
usually be cost-effective, except in a high risk situation. We
will cover the principles and outline the technique.
• Apply a number of ‘guide words’ to the statement of
intention, so that every possible deviation from the
required intention is considered. The main guide words
are:
NO or NOT
Negation of intention, e.g.
no flow.
MORE
Quantitative increase, e.g.
high pressure.
LESS
Quantitative decrease, e.g.
low temperature.
AS WELL AS
Qualitative increase, e.g.
impurity present.
PART OF
Qualitative decrease,
e.g. only one of two
components present
REVERSE
Logical opposite of
intention, e.g. backflow.
OTHER
THAN
Complete substitution, e.g.
flow of wrong material.
HAZOPs are a form of structured “brainstorming”.
© RRC International
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Failure Tracing Methodologies
Let us consider a simple example.
In a batch process, two substances, A and B, are pumped
from their respective storage vessels into a reaction vessel:
Parameter
Guide word
Deviation
Cause
Consequence
Actions
Flow of ‘A’
No
No flow
Pump failure
Incorrect product/
reaction doesn’t
occur
Indicate pump working
at control panel.
Pump off
Line blockage
Maintain lines
Level control on tank,
etc.
Tank empty
Reactor full
More
More flow
Pump at wrong rate Incorrect product/
reaction doesn’t
occur
The design intention is for equal amounts of A and B to be
pumped into the reactor vessel.
We can identify two parts to this system:
• Storage vessel A and the pipeline and pump to the
reactor vessel.
• Storage vessel B and the pipeline and pump to the
reactor vessel.
Let us apply the first guide word “NO” to the first part. In
this case it would mean “no flow”.
Think of some reasons why there might be no flow in the
pipeline.
Here are some suggestions:
• Pump A has failed.
• Pump A not switched on.
• Storage vessel A is empty.
• Reactor vessel is full.
• Pipeline blocked.
Having established the possible causes of this deviation we
then need to make an estimate of the risk for each cause.
In other words:
Automatic control of
pump rate
Having assessed the risk, we need to determine whether
the existing control measures are adequate, or whether
we need to add additional ones. In our example we might
introduce a level gauge in the storage tank and reactor
vessel, each linked to an alarm so that the operator of the
plant would know when the levels were too high or too
low. We might introduce a more reliable pump or even a
second (redundant) pump that could take over should the
first one fail.
Having considered this deviation we would then move on
to the next guide word, which in this case would mean
“more flow”. Having examined flow we would move on to
other parameters such as temperature and pressure, and
apply the guide words again.
Clearly even a relatively simple system can result in a
significant and lengthy analysis. For a major plant it can
take considerable time and involve significant expenditure.
Fault Tree Analysis (FTA) and Event Tree
Analysis (ETA)
Be careful not to get confused between these two
techniques; they are, in fact, complementary (and are often
used together) but focus on opposite sides of an undesired
event. The following figure shows how they fit together:
• How likely is this deviation?
• How soon would we know that the deviation had
occurred?
• What are the consequences?
• How serious are the consequences?
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Failure Tracing Methodologies
Looking at Undesired Events - Using Failure Tracing Methods
Multiple Consequences after event
Multiple Causes leading to event
initial
undesired
event
Preventive
measures
Mitigation
measures
The focus of ETA
The focus of FTA
Relationship between FTA and ETA (‘Bow-Tie’ model)
The figure only shows a single ‘undesired event’; in reality,
multiple causes can lead to many different events initially,
each then escalating with multiple consequences. You can
analyse each event with FTA and ETA. In summary, FTA is
concerned with analysing faults which might lead to an
event, whereas ETA considers the possible consequences
once an undesired event has taken place. Both can be
applied qualitatively or, if you have the data, quantitatively.
Fault Tree Analysis (FTA)
In many cases there are multiple causes for an accident or
other loss-making event. Fault tree analysis is one analytical
technique for tracing the events which could contribute. It
can be used in accident investigation and in a detailed risk
assessment.
The fault tree is a logic diagram based on the principle of
multi-causality, which traces all branches of events that
could contribute to an accident or failure. It uses sets of
symbols, labels and identifiers. For our purposes, you will
only need a handful of these:
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Failure Tracing Methodologies
EVENT
AND gate
OR gate
Basic fault
A fault tree diagram is drawn from the top down (like an
upside down tree). The starting point is the undesired
event of interest (called the Top Event because it gets
placed at the top of the diagram). You then have to
logically work out (and draw) the immediate and necessary
contributory fault conditions leading to that event.
These may each in turn be caused by other faults and
so on. Each branch of the tree is further developed until
a primary failure (such as a root cause) is identified. It
could be endless (though, in fact, you will naturally have
to stop when you get as far as primary failures). The most
difficult part is actually getting the sequence of failure
dependencies worked out in the first place. Let’s look at a
simple example of a fire to illustrate the point.
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Failure Tracing Methodologies
Fire
Fuel
Paper
Petrol
Ignition
source
Oxygen
Discarded
cigarette
Plastic
Electrical
fault
Deliberate
Fault tree analysis of a fire
The above figure shows a simple fault tree for a fire.
HINTS AND TIPS
Don’t worry about getting the symbols precisely
right when you draw fault trees by hand; you can
make your intentions quite clear by writing AND
or OR in the appropriate logic gate as well. Also,
as long as you describe the fault/failure in a box,
don’t worry too much about the (sometimes subtle)
distinction between what should go in rectangles
and circles.
For the fire to occur there needs to be:
Notice we use an AND gate to connect them here because
all three need to be present at the same time to allow
the Top Event. The example shows that, in this scenario,
there happen to be three possible sources of fuel and three
possible sources of ignition. An OR situation applies in
each case, because it would only need one of these to be
present. The example also shows a single source of oxygen
(e.g. the atmosphere).
To prevent the loss taking place, we would first examine
the diagram for AND gates. This is because the loss can be
prevented if just one of the conditions is prevented.
Fault trees can also be quantified, but need relevant data
on the respective probabilities of each of the sub events.
Let’s try this on the same example.
• Fuel.
• Oxygen.
• An ignition source.
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Failure Tracing Methodologies
From previous experience, or as an estimate, a probability
for each of the primary failures being present or occurring
can be established, shown in the following figure (these are
purely illustrative):
Fire
Fuel
Ignition
source
Oxygen
1
Paper
Petrol
Plastic
Discarded
cigarette
Electrical
fault
Deliberate
0.1
0.02
0.09
0.2
0.05
0.1
(We’ve assigned a probability of 1 for oxygen being
present, as it is always in the surrounding atmosphere.)
We can then use two well-established rules of combination
of these probabilities and progress up the diagram to get at
the probability of the Top Event (fire) occurring. Essentially
we:
• Add the probabilities which sit below an OR gate
(this isn’t strictly correct, but is a ‘rare event’
approximation).
• Multiply the probabilities which sit below an AND gate
So, in this example, combining probabilities upwards to the
next level gives:
Probability of FUEL being present = 0.1 + 0.02 + 0.09 =
0.21.
Probability of OXYGEN being present = 1.
Probability of IGNITION being present = 0.2 + 0.05 +
0.1 = 0.35.
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Failure Tracing Methodologies
Updating the figure:
Fire
0.1 + 0.02 + 0.09 = 0.21
Fuel
Ignition
source
Oxygen
0.2 + 0.05 + 0.1 = 0.35
1
Paper
Petrol
Plastic
Discarded
cigarette
Electrical
fault
Deliberate
0.1
0.02
0.09
0.2
0.05
0.1
Moving up again, we can now calculate the probability of
the Top Event. These faults are below an AND gate, so we
multiply the probabilities, giving 0.21 × 1 × 0.35 = 0.0735.
The fully quantified fault tree then looks like this:
© RRC International
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Failure Tracing Methodologies
0.21 × 1 × 0.35 = 0.0735
Fire
0.1 + 0.02 + 0.09 = 0.21
Fuel
Ignition
source
Oxygen
0.2 + 0.05 + 0.1 = 0.35
1
Paper
Petrol
Plastic
Discarded
cigarette
Electrical
fault
Deliberate
0.1
0.02
0.09
0.2
0.05
0.1
So the probability of the Top Event is 0.0735.
You are probably wondering what this number means.
Well, if the probability was 0.1, this would mean there was a
1 in 10 chance of it occurring (i.e. 1/0.1 = 10).
If it was, say, 0.25 then this represents 1/0.25 = 4, i.e. a 1 in
4 chance, so 0.0735 means 1/0.0735 = 13.6, i.e. nearly a 1
in 14 chance of the fire occurring.
HINTS AND TIPS
To get maximum marks in the exam, make sure that
you show all your workings when quantifying a fault
tree.
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Failure Tracing Methodologies
Event Tree Analysis (ETA)
Unlike identifying the root causes of an event under
consideration, ETA is concerned with identifying and
evaluating the consequences following the event.
In FTA the main event is called the Top Event, whereas in
ETA it is called the Initiating Event.
Event trees are used to investigate the consequences of
loss-making events in order to find ways of mitigating,
rather than preventing, losses.
The stages involved in carrying out an event tree analysis
are:
• Identify the Initiating Event of concern.
• Identify the controls that are assigned to deal with the
Initiating Event, such as automatic safety systems, and
other factors that may influence the outcome, such as
wind direction or presence of an ignition source that
would be important if there was an escape of a large
amount of liquefied petroleum gas.
• Construct the event tree beginning with the Initiating
Event and proceeding through the presence of
conditions that may exacerbate or mitigate the
outcome.
• Establish the resulting loss event sequences.
• Identify the critical failures that need to be dealt with.
• Quantify the tree if data is available to identify the
likelihood or frequency of each possible outcome.
There are a number of ways to construct an event tree.
They typically use binary logic gates, i.e. a gate that has
only two options, such as success/failure, yes/no, on/
off. They tend to start on the left with the Initiating Event
and progress to the right, branching progressively. Each
branching point is called a node. Simple event trees tend to
be presented at a system level, glossing over the detail.
Let us illustrate the process with a simple example where
the Initiating Event is a fire:
Fire
detected?
Initiating event
Fire
Yes
No
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Failure Tracing Methodologies
The ETA diagram shows the Initiating Event on the left,
leading to a mitigation measure: “Is the fire detected?”
The answer to this question is a simple YES or NO, so the
tree now branches to represent whether the answer to the
question is YES or NO. Detection of the fire is, of course,
the first step in minimising the consequence of the fire
so now we need to consider those other factors that are
necessary that will either minimise the outcome, or make
the situation worse.
Fire
detected?
Fire alarm
works?
Sprinkler
works?
Limited
damage
Yes
Yes
No
No
Fire
Yes
Yes
Extensive
damage
Limited damage
Wet people
No
No
Possible fatalities
Extensive damage
In this example, apart from detecting the fire we need
to have an effective alarm system to alert persons in the
building and an effective sprinkler system. The detection
system switches on the alarm and then the sprinkler. Each
factor is considered as to whether it occurs or does not
occur, each leading to a further branch in the tree.
You will also note that in this example, should the fire not
be detected, the alarm will not sound nor will the sprinkler
operate, so if the fire is not detected there will be the
worst outcome.
At the end of the branches on the right of the tree you can
see the different outcomes identified, depending on the
success or otherwise of the intervening factors.
In binary logic, an event either happens, or does not. Let us
suppose that the probability the fire is detected is 0.95; this
means 95 out of every 100 times a fire takes place it will be
detected. It follows that the probability it is not detected is
0.05, i.e. 5 out of every 100 times.
So the:
Probability of success + Probability of failure =
0.95+0.05=1.
In all binary events the sum of the two probabilities must
always equal 1.
To quantify an event tree we need to know the
probability for each of the outcomes that follow from the
Initiating Event - the probability that:
• The fire is detected;
• The alarm works; and
• The sprinkler works.
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Failure Tracing Methodologies
Here is the tree with the probabilities for the three events
after the Initiating Event.
Fire
detected?
Sprinkler
works?
Fire alarm
works?
P = 0.9
Limited
damage
Yes
P = 0.99
Yes
No
P = 0.1
P = 0.9
P = 0.95
No
f = 0.01/y
Yes
Yes
Extensive
damage
Limited damage
Wet people
P = 0.01
Fire
No
No
P = 0.1
P = 0.05
Possible fatalities
Extensive damage
As we noted above, the sum of the probabilities for each
event is always 1.
You will also notice that we have included the frequency
of the Initiating Event, i.e. the fire, which is 0.01/y which
means a fire will occur on average once every 1/0.01 years,
i.e. once every 100 years.
We can now calculate the frequency of each of the
possible sequences identified in the tree by multiplying the
probabilities for each sequence and then multiplying this
by the frequency of the Initiating Event.
So for the sequence leading to “Limited damage” we have:
Frequency of fire (0.01/y) x Fire detected (0.95) x Fire
alarm works (0.99) x Sprinkler works (0.9) = 0.0085.
This means this outcome will occur (on average) once
every 1/0.0085 years = 118 years.
In contrast, the sequence in which the fire is not detected
will occur with a frequency of 0.01 × 0.05 = 0.0005/y
which is once every 1/0.0005 years = 2000 years.
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Failure Tracing Methodologies
Here is the tree with the expected frequencies for each of
the outcomes:
Fire
detected?
Fire alarm
works?
Sprinkler
works?
P = 0.9
Yes
P = 0.99
Limited
damage
f = 1:117.65y
P = 0.0085/y
Yes
No
P = 0.95
No
P = 0.01/y
Yes
P = 0.1
P = 0.9
Yes
P = 0.01
Extensive
damage
P = 0.00094/y
f = 1:1063.83y
Limited damage
Wet people
P = 0.000086/y f = 1:11,627.91/y
Fire
No
No
P = 0.0000095/y
P = 0.1
f = 1:105,263.16/y
P = 0.0005/y
P = 0.05
f = 1:2000/y
Possible fatalities
Extensive damage
What can we conclude from this?
Well, the most probable outcome, should a fire break out,
is that all the controls will work and damage will be limited
(probability = 0.0085). However the second most probable
outcome is the fire not being detected and this leads to
extensive damage and possible fatalities (probability =
0.0005).
What would we recommend?
One solution would be to increase the reliability of the
fire detection system. However, this is a crucial link in
the sequence, since if it fails then the reliability of the
alarm and sprinkler become irrelevant. A much better
improvement would be to include a second detector,
independent of the first. This would mean that BOTH
detectors would have to fail, which is a much less likely
event.
The following is a similar example. The figure shows a
quantified event tree for the action following a fire on
a conveyor system. Here the fire detector, i.e. the heat
sensor, opens the valve leading to operation of the water
sprays. As in the previous example, should the sensor fail,
the success of the valve or water spray is not relevant to
the outcome; but here, should the valve fail, the success of
the water spray becomes irrelevant.
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Failure Tracing Methodologies
Heat
sensor
detects
Valve
operates
Water sprays
operate
0.7
0.8
0.3
0.9
0.2
Outcome
frequencies
2 × 0.9 × 0.8 × 0.7 = 1.008/yr
2 × 0.9 × 0.8 × 0.3 = 0.432/yr
2 × 0.9 × 0.2 = 0.36/yr
Conveyer belt fire
(of frequency 2/year)
0.1
2 × 0.1 = 0.2/yr
Success state
Failure state
The only outcome resulting in control of the event is
where the sensor, valve and water spray operate (the
example is a little contrived but serves to demonstrate the
principles).
Notice how the frequencies of the outcomes are
calculated. Notice also that the sum of all the outcome
frequencies adds up to 2 in this case, i.e. the frequency of
the Initiating Event (the conveyer belt fire).
The event tree could be used to check that there were
adequate fire detection, warning and extinguishing
systems.
REVISION QUESTIONS
7. The frequency of pipework failure in a large
LPG storage facility is estimated at once every
100 years (f=0.01/year). Immediate ignition of
the released gas (probability, p=0.05) will result
in a jet flame. Otherwise, prevailing winds will
normally carry any vapour cloud off site across
open countryside where it will disperse safely.
However, under certain conditions (p=0.1), the
cloud may drift to a nearby industrial estate
where ignition (p=0.5) will cause a vapour cloud
explosion or flash fire.
Using the data provided, construct an event tree
to calculate the expected frequency of fire or
explosion due to pipework failure BOTH on site
AND on the industrial estate.
8. Outline the basic principles of a hazard and
operability study.
9. Briefly explain the difference between an “event
tree” and a “fault tree”.
(Suggested Answers are at the end.)
© RRC International
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Summary
SUMMARY
Sources of Information to Support Hazard Identification and Risk Assessment
We considered commonly used accident and disease ratios - incidence rate, frequency rate, severity rate and
prevalence rate.
Information can be sourced both externally and internally:
• External sources include: national governmental enforcement agencies, international bodies, professional and
trade bodies, and insurance companies.
• Internal sources include: accident reports, absence records and maintenance records.
Hazard Identification Techniques
Various techniques can be used to detect hazards including: task analysis, checklists, observations and incident
reports.
A checklist which covers the key issues to be monitored is developed to ensure a consistent and comprehensive
approach to checking all the safety elements to be covered during an inspection.
The analyst should make an observation of the work being done, including work undertaken by groups of operators.
Assessment and Evaluation of Risk
We looked at the key steps that characterise all risk assessments:
• Hazard identification.
• Identify who is at risk.
• Estimation, evaluation of risk and identifying precautions.
• Record significant findings and implement.
• Review the assessment.
Assessments should ensure suitable and sufficient coverage of risk. This means that:
• They should identify the significant hazards.
• The detail should be proportionate to the risk, with the most hazardous operations requiring the most
sophisticated assessments.
• In some cases more analytical techniques may be necessary (e.g. high noise levels).
• The period for which it is likely to remain valid should be identified.
Types of risk assessment include:
• Qualitative - risks are represented by simple word descriptors.
–– Risk = Probability (or Frequency) x Consequence (or Harm or Severity).
–– Probability is the chance that a given event will take place.
–– Severity of risk is the outcome.
• Semi-quantitative - results represented by qualitative and quantitative descriptions. In some the risk is expressed
as a number which indicates rank and not an absolute value.
• Quantitative - risks are represented by the frequency or probability of a specified level of harm, from a specified
activity.
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Summary
Organisational arrangements for risk assessment include:
• Plan - what you want to achieve, who will be responsible for what, how you will achieve your aims, and how you
will measure your success.
• Do - identify your risk profile, organise your activities to deliver your plan.
• Check - measure your performance, assess how well the risks are being controlled and investigate the causes of
accidents, incidents or near misses.
• Act - review your performance and take action on lessons learned, including from audit and inspection reports.
Once hazards have been identified, the risk they pose needs to be assessed and prioritised.
Failure Tracing Methodologies
Principles and techniques of failure tracing methods:
• HAZOPS is:
–– A method designed for dealing with complicated systems where failures can affect other parts of the system.
–– Used, for example, at large chemical plants.
• Fault tree analysis starts with a Top Event and identifies the necessary preceding events and their combination
that are necessary for the Top Event. It identifies causes.
• Event trees start with an Initiating Event and look at the consequences through the failure of control measures
and the effect of other events.
© RRC International
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Exam Skills
QUESTION
This is the first example of a 20 mark, Section B question for you to work on. It is split into three sub-questions and is
based on a scenario.
You should allow 30 minutes to answer a Section B question in the exam.
Question
An employer wishes to build a new gas compression installation to provide energy for its manufacturing processes.
An explosion in the installation could affect the public and a nearby railway line. In view of this the employer has
been told that a qualitative risk assessment for the new installation may not be adequate and that some aspects of
the risk require a quantitative risk assessment.
(a) Explain the terms ‘qualitative risk assessment’ AND ‘quantitative risk assessment’.
(b) Identify the external sources of information and advice that the employer could refer to when
deciding whether the risk from the new installation is acceptable.
(c) A preliminary part of the risk assessment process is to be a hazard and operability study.
Describe the principles and methodology of a hazard and operability (HAZOP) study.
(5)
(5)
(10)
APPROACHING THE QUESTION
At first sight this might seem like a complicated question,
but don’t be put off by it as it isn’t as bad as it looks.
HINTS AND TIPS
I suggest that you re-read the appropriate sections of the
element and think about the terms asked about in the
question. This will help to get things clear in your mind.
This question isn’t about chemical process safety (which
is examined in Unit IC of the International Diploma), but
about risk assessment techniques.
As you write your answer make sure that you refer
back to the scenario described in the question to
ensure that your answer has the correct emphasis.
Think about the marks available for the three parts of the
question, and your timing.
Put together an answer plan for part (a) of the question
around the terms “qualitative” and “quantitative” risk
assessment. Remember that there are only 5 marks
available for this part so the Examiner is not looking for
lots of information - just that you can show that you
understand the terms and the differences between them.
Part (b) requires a list of sources of guidance, so
reference to national governmental enforcement
agencies and international bodies would be appropriate
here. Remember that part (c) refers to a HAZOP so
the Examiner is looking for sources relating to how you
conduct a HAZOP and decide on an acceptable level of
risk.
Part (c) is worth 10 marks so you need an answer plan that
covers 10/12 points that you know about how a HAZOP is
conducted in order to get full marks. Use bullet points and
expand each point to show that you understand what you
are saying.
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Exam Skills
SUGGESTED ANSWER OUTLINE
This looks like a hard question, but remember that you
can’t expect to find every question easy to answer. You
need to accumulate marks from your stronger questions
and then work on getting 50% in the other questions to
spread your mark risk.
HINTS AND TIPS
You might get good marks for any or all of parts (a), (b)
and (c) and they all count to your overall total so have a go.
In part (a) the Examiner would have wanted you to explain
the differences between the two terms, so make sure you
get them the right way round or you lose all the marks
here!
The Examiner can set any questions based on the
syllabus and related to the Learning Outcomes. Just
because you don’t use a certain type of process does
not mean that there won’t be a question on it.
Remember that you are expected to show that you
can apply your knowledge and understanding to
both familiar and unfamiliar situations.
• Qualitative: informed subjective judgments; needs
good hazard identification process and looks at
likelihood of hazards occurring and severity of their
consequences. Can be number or ranked (High, Med,
Low, etc.).
• Quantitative: numerical, based on frequency/
probability of events happening and their consequence;
an objective approach which relies on specific data or
comparison with specific criteria.
In part (b) the Examiner was concerned with the issue of
tolerability, so the UK HSE’s publication “Reducing Risks,
Protecting People” would be a great source to mention, as
would be similar guidance which talks about tolerability.
Other sources could be experts, consultants, other
organisations with similar installations or design
companies, as well as insurance companies.
In part (c) you would need an understanding of how
HAZOP studies operate, so you should mention
identification of deviations from intended normal
operation and that HAZOPs are best carried out at design
stage of installation but can be used for modifications to
processes/installations.
HAZOP studies have a team leader; there has to be
awareness of the scope of the study which is to be
conducted by the team. The installation/process is broken
down into key parts/elements (known as “nodes”); you
need objective data and information to support the study.
The study involves brainstorming and the use of guide
words which are then applied methodically to each
process parameter to form “deviations” from normal
operating conditions. Examples of process parameters
include flow, pressure, temperature and concentration,
whereas guidewords include no, more, less and reverse. An
example deviation would therefore be “less flow” or “more
concentration”. You would need to mention that the
study looks at possible causes and consequences of each
deviation and will identify possible corrective actions.
The study also needs to be documented and you can use a
set format, which is then recorded and kept in the project
file or H&S file.
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Exam Skills
POSSIBLE ANSWER BY EXAM CANDIDATE
(a) The terms qualitative and quantitative refer to the way the risk assessments are conducted.
Qualitative – as the word suggests this is a subjective approach to deciding on the level of risk; it looks at likelihood
of incidents occurring and the severity of injury or damage to people or the environment from those incidents. It will
be ranked and a typical approach is to rank them HIGH, MEDIUM or LOW risk.
Quantitative – this is a numbers-based approach using data/frequencies of events happening and their consequence
and is used more formally for higher risk applications, as it is an objective approach to assessing the risk.
(b) An employer could consult, externally, consultants who are experts in the installation/topic, industry guidance,
manufacturers of the equipment to find out failure rates and types of incidents; insurance providers will also be able
to put employers into contact with advice and guidance and support the employer with information. The HSE, the
OSHA, the European Safety Agency, the ILO and the World Health Organisation are all good sources of information
and their websites may have good guidance on reducing risks.
(c) A hazard and operability study (HAZOP) is a formal type of risk assessment which follows a set format, with a
study leader gathering a team of people, who would consist of supervisors, operators, maintenance staff, designers,
H&S professionals, etc. The team will follow a checklist which looks at the plant operating parameters, such as flow,
temperature and pressure, together with agreed guide words, e.g. no, more, less, part of and reverse. Each parameter
is combined with each guide word to identify possible deviations from the designed operating conditions. The
possible causes of the deviations are then discussed, together with possible controls to prevent such deviations.
The process should take place at the design stage of new facility/plant or before modifications to existing take place.
This study should have an action plan which should be managed to ensure the plant is designed safely; anything that
needs operational controls should be identified and this information acted upon by the operational department. The
study should be kept as part of the H&S file for the installation.
HINTS AND TIPS
In your part (b) answer do not be tempted to give
more than four examples – you won’t gain any extra
marks by giving five!
REASONS FOR POOR MARKS ACHIEVED BY CANDIDATES IN EXAM
This was not a popular question when it appeared on a Diploma paper (possibly people were scared off by the term
HAZOP), but an exam candidate who did answer this question would achieve poor marks for:
• Getting terms muddled up.
• Not linking the parts of the question back to the scenario (a complex high-risk installation which needed a good
understanding of risk and tolerability).
• Not identifying relevant external sources of information for this complex installation.
• Showing no real understanding of the HAZOP process.
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ELEMENT
RISK CONTROL
5
LEARNING OUTCOMES
On completion of this element, you should
be able to demonstrate understanding
of the content through the application
of knowledge to familiar and unfamiliar
situations and the critical analysis and
evaluation of information presented in
both quantitative and qualitative forms. In
particular you should be able to:

Outline
common risk management strategies.
factors to be taken into account when
Outline
selecting risk controls.

© RRC International
Explain
the development, main features and
operation of safe systems of work and permit-towork systems.
Unit IA – Element IA5: Risk Control
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Contents
COMMON RISK MANAGEMENT STRATEGIES
Concepts Within a Health and Safety Management Programme
Selection of Optimum Solution Based on Relevant Risk Data
Revision Question
5-3
5-3
5-6
5-7
FACTORS TO BE TAKEN INTO ACCOUNT WHEN SELECTING RISK CONTROLS
General Principles of Prevention
Categories of Control Measures
General Hierarchy of Control Measures
Factors Affecting Choice of Control Measures
Cost-Benefit Analysis
Revision Questions
5-8
5-8
5-10
5-10
5-11
5-11
5-13
SAFE SYSTEMS OF WORK AND PERMIT-TO-WORK SYSTEMS
Safe Systems of Work
Use of Risk Assessment in Developing and Implementing a Safe System of Work
Permit-to-Work Systems
Revision Questions
5-14
5-14
5-16
5-17
5-22
SUMMARY
5-23
EXAM SKILLS
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Common Risk Management Strategies
KEY INFORMATION
The key risk management strategies are:
• Avoidance or elimination.
• Reduction.
• Transfer.
• Retention with/without knowledge.
CONCEPTS WITHIN A HEALTH AND SAFETY
MANAGEMENT PROGRAMME
Risk management may be defined as:
The identification, measurement and economic control
of the risks which threaten the assets or earnings of a
company or enterprise.
Risk control can be split into loss control and risk
financing.
• Loss control:
–– Risk avoidance.
–– Risk reduction.
• Risk financing:
–– Risk retention.
–– Risk transfer.
A strategy may consist of one, or a combination of these
methods.
Avoidance or Elimination
• Risk avoidance is avoiding completely the activities
giving rise to risk. For example, never travel by air to
avoid the risk of being involved in a mid-air collision.
• Risk elimination usually has a wider meaning; it
implies removal of a risk without necessarily ceasing
an activity completely, e.g. redesign of a process to
remove a particular risk without stopping the activity.
Risk avoidance or risk elimination is the best solution
to the problem of risk. In some cases we will have
estimated the risk of some particular operation to
involve the possibility of a fatality or serious personal
injury. This suggests that avoidance or elimination is an
essential requirement. In eliminating one risk you could
inadvertently introduce other risks. For example, in
automating a process by introducing robots to eliminate,
say, the risk of manual handling, you will introduce some
of the risks associated with robots. Some hazards can be
avoided by completing a task in a slightly different way.
For example, providing a chair for a supermarket checkout
person (rather than expecting them to stand) can remove
hazards associated with physical fatigue.
© RRC International
Reduction
Often avoidance or elimination may not be possible,or
reasonably practicable, or even desirable (if, for example, it
would involve closing a factory with the loss of all jobs and
the high associated cost of redundancy). Risk reduction,
while not as effective, might be a more economically viable
solution.
Unit IA – Element IA5: Risk Control
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Common Risk Management Strategies
Advantages of Risk Retention
GLOSSARY
RISK REDUCTION
This is where risk is not avoided or eliminated
entirely, but attempts are made to reduce the
frequency and/or severity of a potential loss by
use of typical safety control techniques such as
engineering solutions to control risk at source,
procedures and behavioural measures (training, etc.).
Risk Retention
Here the loss is to be financed from funds within the
organisation, so we have to consider where the funds are
to come from.
Sources of Funds
Possible sources are:
• The full sum of insurance premiums is never paid out,
so risk retention can be cheaper than insurance. The
insurance company has to make a profit, both for
future finance, and for its shareholders. A millionaire
does not take out maximum insurance for his car; if it
is damaged, he just buys another one. The good car
driver or employer pays, through his premiums, for
the poor driver or employer. Insurance is profitable for
poor risk managers, but not for a good risk manager.
• Retention reduces the cost both of processing claims
and the detailed accounting required. The loss occurs
and you just pay out.
• If costs are allocated to departments, management
becomes more risk conscious. This is a vital feature in
risk management; it is pointless for a departmental
manager to go all out for production profit and then
have to use his or her profits to pay for accidents and
losses.
• Losses are dealt with quickly.
• Pay losses from current operating funds. Payments
should be restricted to a maximum of about 5% of the
operating costs. Losses must be predictable.
You should think about each advantage and see whether it
applies to your organisation.
• Use an unfunded reserve, such as depreciation. This is
where some large item of capital expenditure is written
off over a number of years. The problem is that the
fund does not actually exist except as an accounting
convenience. There is no tax advantage and no actual
ready cash.
With knowledge means you have made a conscious
decision to bear the burden of losses; without knowledge
means it is done without any consideration whether or not
to insure.
• Use a funded reserve, e.g. a fund of cash or easily
obtained cash. It could be a group fund. There is no tax
advantage. It takes time to build up such a reserve, so
care is required in the early years. There is low interest
on capital. If you wish to obtain a good rate of interest,
you will have to give notice before you can withdraw
funds. The fund needs to gain interest, but should be
readily available when required.
Risk Retention - With or Without Knowledge
Every risk that is not transferred (to insurance) is a retained
risk. Examples are:
• Insuring through a captive insurer (see later).
• Events which are insurable. You cannot get insurance
for everything. The insurance company has to be able
to assess risk, since they are in the business of risk
management. They may quote a premium that is above
the value you wish to insure. If you can buy a new item
for the price of the premium, it is pointless to insure.
Take the risk instead.
• Borrowing to restore losses, which is not easy after a
loss occurs. For example, if you had just had a large fire
at the factory, the bank would be reluctant to lend and
would make a lot of expensive conditions.
• Losses not considered when setting up insurance - if
you do not take into account a particular possibility,
you are retaining the loss. It is a case of accidental risk
retention, or risk retention by default.
• Divert funds from planned capital investment; the
company then uses funds set aside to buy an important
capital item because there is a loss which has to be paid
for.
• Hazards deliberately not insured - risk management
is all about taking a risk, where you have been able to
reduce either the probability or the severity of a lossmaking event.
If you consider each of these options, you will realise that
there is no readily available, inexpensive source of finance
to pay for any loss. On the other hand, there are some
good reasons for considering risk retention.
• Losses outside the scope of the insurance - there are
always exclusion clauses, and you do not realise their
significance until you need to make a claim. The good
risk manager does not find himself or herself in such a
situation.
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Common Risk Management Strategies
• The part of the loss paid by the company (the
excess) - you can get cheaper insurance if you agree to
pay the first £x of any claim.
• The part of the loss which is above the limits of the
contract - there is often an upper limit to an insurance
claim. The claimant pays if the loss exceeds that figure.
• The person or company is unable to pay full
compensation - obtaining the cheapest insurance
cover may not be sound economy if your losses put
them into bankruptcy.
Risk Sharing
Risk management is really a type of risk sharing and
involves financing risks which are manageable and
transferring those which are not.
Methods include:
• A deductible portion of excess - you pay the first part
of each claim.
• Re-insurance.
Transfer involves transferring the risk to another party such
as by insurance - the loss is financed from funds which
originate outside the organisation. The second main way is
to engage a contractor who will take on the risks.
• Co-insurance - the insurer pays a percentage of the
claim. This is another way of reducing a premium. You
share the risk with the insurer by paying not only an
excess but a percentage of the losses which fall within
a certain price range; paying another percentage of
those in another range; and the insurer paying all losses
above a set figure.
Insurance
An Important Point
How can you reduce insurance premiums? One way is to
retain losses; another way is to accept a voluntary excess
on insurance premiums and control losses.
A good risk manager will make his greatest savings in the
area of insurance by:
Advantages of insurance are that:
• Considering very carefully those areas where the risk
has significantly been reduced.
Risk Transfer
• The loss will be dealt with smoothly. There will be a few
forms to fill in and enquiries, but the procedures are
well known.
• Not insuring where the risk has been eliminated.
• Paying for the retained risks where it is cheaper than
insuring.
• The cash is available. The insurer can get hold of the
funds quickly, though will perhaps not release them as
quickly as you would like.
• The insurer can provide advice. He is dealing with
this type of problem all the time and can help you to
decide what is best.
Use of Specialist Contractors
Sometimes the best way of avoiding a hazard is to make
use of specialist contractors, e.g. for the removal of
asbestos. In this way the hazard is avoided by workers and
the task is carried out professionally and in compliance
with current legislation. A reputable company with suitably
trained personnel and a good safety record should be used.
© RRC International
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Common Risk Management Strategies
SELECTION OF OPTIMUM SOLUTION BASED
ON RELEVANT RISK DATA
The selection of the optimum solution must take into
account the type of organisation and the relevant risk data.
The risk assessment will be a vital part of the exercise. If the
probability is high and the severity is also high, then it will
be important to do a great deal and spend a lot of finance
to achieve a valid solution. If the probability or the severity
is low, then it will not warrant too great an expenditure.
Study the following table carefully:
Probability
Severity
Action
Definite
High
Eliminate
Medium
Fund (cheaper than insurance)
Low
No action - operating expense
High
Eliminate or reduce probability or severity
Medium
Reduce severity
Low
Retain as an operating expense
High
Reduce severity
Medium
Reduce severity or transfer
High
Medium
Low
Remote
Low
Retain as an operating expense
High
Fund or insure
Medium
Fund
Low
Retain as an operating expense
Catastrophic
Insure, or fold company
High
Fund, insure, or fold company
Medium
Fund or retain as an expense
Low
No action
Other important factors include:
• Present State of Technology
With technology improving all the time new solutions
become available; as computers have improved, the
price of this technology has reduced. The safety
practitioner must keep up to date with technology and
consider how it could help the safety solutions.
• Public Expectancy
After a disaster a journalist often asks: “Can you
guarantee that nothing like this will ever happen again?”
Remember that human beings make mistakes, and
no machine is infallible. Earthquakes occur without
warning, and we can do little to control the effects of
freak weather.
5-6
A major problem is that the general public is never
realistic in assessing relative risk. Car accidents cause
more deaths than public transport, but seldom hit
the national headlines. Atomic energy is probably one
of the safest power sources. Most deaths are from
cancer, heart disease and stroke, and very few are from
industrial causes. Most people would make a poor job
of rating industries by their accident potential.
• Legal Requirements
‘Learning by accident’ is a way of describing how safety
legislation has developed over the years. Industrial
accidents and disasters were the basic reason for the
introduction of much of the existing safety legislation.
Mines and factories were the cause of many fatalities
while industry was developing, so legislation was
enacted to control them. Now legislation tends to be
more proactive, setting broad standards that have
to be adhered to in order to control risk, rather than
reactively responding to specific incidents.
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Common Risk Management Strategies
• Economic State of the Company
The economic state of the company is no excuse for
not meeting legal standards - it can be used as a reason
for not going for a higher standard. It is not good
economic sense to skimp on safety, since all accidents
produce a loss. However, a company with vast profits
can afford to spend more than one with financial
restraints. Companies’ economic goals will influence
the approach to risk control. These may range from
simple cost covering to survive, to profit maximisation.
Risk management must balance the cost of controls
against the estimated reduction in potential loss from
risks.
• Levels of Insurance Premiums
Premiums are set by the level of claims. The insurance
company is in business to make a profit. Good
companies pay their premiums and do not make
claims; it is the bad companies who benefit from
insurance. If the premiums are reasonable, it is better
to take the precaution of insurance. However, if
premiums become excessive, then it will be better to
retain the risk.
• Confidence of the Company in the Benefits of Risk
Management and in the Competence of the Risk
Manager
A good company, with good control of risk, will opt
to retain risk rather than insure or transfer the risk. As
the situation and the confidence improve, there will be
increased movement towards this method of solution.
If the company is able to use a captive insurance
company, there will be less reliance on outside risk
transfer.
• Human Factors
Accidents and incidents have an associated direct cost
but can also influence the culture of the organisation.
Frequent loss-making events can have a bad effect on
morale, which can lead to a reduction in efficiency and
higher overall costs. Consequently, a wish to improve
industrial relationships can influence the approach to
risk control measures.
REVISION QUESTION
1. What are the main risk management strategies?
(Suggested Answer is at the end.)
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Factors to be Taken Into Account When Selecting Risk
Controls
KEY INFORMATION
• The following are well recognised general principles of risk prevention:
–– Avoid risks.
–– Evaluate.
–– Combat at source.
–– Adapt work to the individual - ergonomics.
–– Adapt to technical progress.
• Control measures may be classified as being technical, procedural or behavioural.
• The choice of control measures adopted should take account of:
–– Use in the long or short term.
–– Applicability.
–– Practicability.
–– Cost.
–– Effectiveness.
–– Legal requirements.
–– Competence/training needs.
• Cost-benefit analysis is a useful tool to aid the decision-making process.
GENERAL PRINCIPLES OF PREVENTION
Having identified the risks, measured their effect upon
the company, and developed some kind of priority, we
then have to do something about them. In practice, we are
probably doing each of these stages at the same time:
• Recognise.
• Measure.
• Evaluate.
• Control.
• Monitor.
• Review.
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Factors to be Taken Into Account When Selecting Risk
Controls
TOPIC FOCUS
Preventive and Protective Measures
There are some well recognised general principles of prevention:
• Avoiding risks.
Not using the material (e.g. toxic chemicals) or carrying out the activity (e.g. excavations) eliminates the need for
control.
• Evaluating the risks which cannot be avoided.
Risk evaluation is an essential part of the risk assessment process. It is where the level of risk is compared against
agreed risk criteria. This helps you decide on the most appropriate risk control options.
• Combating the risks at source.
Control the risk as close to the point of generation as possible to prevent its escape into the workplace (e.g.
extract dust directly from a circular saw blade using LEV).
• Adapting the work to the individual, especially as regards the design of workplaces, the choice of work
equipment and the choice of working and production methods, with a view to alleviating monotonous work and
work at a predetermined work-rate and to reducing their effect on health.
The traditional approach has always been for the person to adapt to the machine or process. This measure
requires the employer to carefully consider ergonomic principles and design the work to suit the person.
• Adapting to technical progress.
Many risks disappear from the workplace as better processes and methods are introduced. For example, the
replacement of traditional machine tools by CNC (Computer Numerical Control) machines, primarily for
production efficiency, also removes the need for manually adjusted guards on lathes and milling machines.
• Replacing the dangerous with the non-dangerous or the less dangerous.
This is always a key aim, and an example of this is the replacement of the metal-cased, hand-held mains electric
drill by rechargeable, battery-operated, plastic-cased drills.
• Developing a coherent overall prevention policy which covers technology, organisation of work, working
conditions, social relationships and the influence of factors relating to the working environment.
This embodies the principles of risk management and requires the employer to look at all aspects of the health
and safety management system rather than simply concentrating on basic workplace precautions.
• Giving collective protective measures priority over individual protective measures.
A safe place of work should be the main priority rather than a safe person, so control of noise at source should be
the aim rather than the issue of hearing protection.
• Giving appropriate instructions to workers.
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Factors to be Taken Into Account When Selecting Risk
Controls
CATEGORIES OF CONTROL MEASURES
Control measures are often categorised into one of three
different types.
TOPIC FOCUS
• Technical - the hazard is controlled or eliminated by
designing a new machine or process, or by producing
some guarding measure.
Hierarchy of Control Measures
• Procedural - such as a safe method of work, e.g.
introducing permit-to-work systems as part of a safe
system of work.
• Behavioural - will involve education and training
of operatives, putting up notices and signs, using
protective equipment and generally making workers
aware of the risks - changing the ‘safety culture’ of the
organisation.
GENERAL HIERARCHY OF CONTROL
MEASURES
In dealing with risks, we must establish an order of
treatment. A quick Internet search will make you realise
that there are a number of different hierarchies, many
of which are very similar; some are specific to control
of chemicals or machinery guarding. One such order of
treatment is:
One hierarchy of control measures (modified from
that in Management of Occupational Health Risks in
the Offshore Oil and Gas Industry) is:
• Elimination
Stop using the process, substance, or equipment,
or use it in a different form.
• Substitution
Replace a toxic chemical with one that is not
dangerous or less dangerous. Use less noisy
pumps.
• Engineered Controls
Redesign of the process or equipment to
eliminate the release of the hazard so that
everyone is protected; enclosure or isolation of
the process or use of equipment to capture the
hazard at source and release it to a safe place, or
dilution to minimise concentration of the hazard,
e.g. acoustic enclosures, use of LEV.
• Administrative Controls
Design work procedures and work systems to
limit exposure, e.g. limit work periods in hot
environments, develop good housekeeping
procedures. Controls may also include: use of
signs, training in specific work methods, and
supervision.
• PPE (as a last resort)
Respiratory protective equipment, gloves, etc. only protects the individual.
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Factors to be Taken Into Account When Selecting Risk
Controls
The items at the beginning of the list are often long-term
objectives and are the responsibility of management. They
are the most effective, but more costly to implement. The
items towards the bottom of the list can be short term and
quickly put into place, but are the least effective. It may be
impossible or prohibitively expensive to eliminate a hazard
in a practical situation. On the other hand, you will get very
few marks in the examination if your solution to a practical
situation is to issue a pair of gloves, or just suggest that a
worker takes more care.
Another example of a hierarchy that is sometimes quoted
is:
• Total elimination or avoidance of the risk at its source.
• Reduction of the risk at its source.
• Contain the risk by enclosure of some kind.
Effectiveness of Controls
No one control measure can be 100% effective, so when
evaluating which measure to adopt you have to take into
account its effectiveness. PPE is of limited benefit because
it only protects the person wearing it and not necessarily
all those at risk. It may be uncomfortable or inconvenient
to wear. The more effective the control, the greater
consideration should be given to its use.
Legal Requirements and Standards
In some circumstances, legislation specifies the controls
needed for a particular hazard. In these situations any
selected control measure will have to meet these standards
as a minimum.
Competence of Personnel and Training
Needs
• Remove the worker from the risk.
• Reduce the worker’s exposure to the risk.
Clearly the control measures adopted for a specific
situation must be such that the user is competent to
use them without them creating a risk to the worker
concerned or others. This may mean additional training
and supervision which are an added cost.
• Use personal protective equipment.
• Train the worker in safe techniques.
• Make safety rules, or issue instructions.
• Tell the worker to be careful.
FACTORS AFFECTING CHOICE OF CONTROL
MEASURES
Long Term/Short Term, Applicability and
Costs
Those points which appear earlier in the list of control
measures will be the most effective in reducing the risk,
but are usually the more expensive and take much longer
to put in place, so can be viewed as long-term objectives.
Although, in practice, it might be technically possible to
achieve total elimination of a hazard, the costs involved
and the benefits achieved may mean that it does not pass
the test of “reasonably practicable”.
Many of the improvements in safety standards have
been due to the reduction in manpower and increasing
mechanisation. Computers can be used to control many
operations and eliminate the use of people in risky
situations. However, they cannot think, and sometimes
the choice is not between right and wrong (1 and 0 to a
computer) but between the lesser of two wrongs.
COST-BENEFIT ANALYSIS
There are costs involved with all accidents and losses.
There will also be costs involved with accident prevention
and risk reduction, in addition to the obvious benefits
of such measures. It is possible to spend more on risk
treatment than we save by the reduction of the losses. This
is why part of risk management is the idea of risk retention.
The methods shown lower in the list of control measures
are usually the cheaper options. They can be put into
operation quickly, and give some measure of risk reduction,
but their effect is of short duration. PPE, although near
the bottom of the hierarchy, may be acceptable for nonfrequent exposure, such as in maintenance tasks.
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Factors to be Taken Into Account When Selecting Risk
Controls
The cost-benefit graph is illustrated below.
Cost-benefit graph
This graph shows the position where there is maximum
benefit.
Cost-benefit analysis is a conceptually simple tool for
helping you make a decision as to whether a particular
course of action or project is in fact viable or cost effective.
So, if you are thinking about upgrading risk control
measures, you will probably need to justify the request
for funding with the aid of a cost-benefit analysis. In its
simplest form, it is an entirely economic argument (rather
than a moral or legal one). It is an essential, persuasive tool
for the safety practitioner because not only is it systematic
and simple, but it is also commonly used and understood
by business people. For this reason, using the UK as an
example, any proposed new regulations are almost always
accompanied by a regulatory impact assessment, which
contains a cost-benefit analysis to assess the financial
impact of the proposals on UK businesses. In the case of
regulatory impact assessments, costs may outweigh the
benefits for certain industries but, if the proposals become
law, the requirements will still have to be implemented.
In principle, you simply add up all the benefits associated
with a programme and then subtract all the costs. In
practice, there are a number of complications:
• Not all costs and benefits can be assigned a
reasonably accurate financial value.
Though we know that intangible concepts such as
‘reputation’, ‘public/shareholder perception’, ‘worker
morale’, and ‘worker co-operation and involvement’
may have an impact on efficiency, productivity,
shareholder investment and sales, their value cannot be
fully quantified financially - though it may be possible
to suggest an estimate.
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• Benefits may not be seen immediately.
It may take several years to achieve sufficient benefits
to ‘break even’. This is known as a payback period.
This includes the benefits of reduction in civil liability
claims and reductions (or no trend of further rises) in
employers’ liability insurance premiums.
• Some costs and benefits are one-off, others are
recurring.
For example, if your project required the purchase
of a new piece of machinery, there is the initial
one-off cost of the machine itself, installation,
commissioning and any specific training. There are
also the annual on-going running costs, such as energy,
maintenance, testing, etc. For ‘software’ projects, such
as implementing a safety management system or a
behavioural safety programme, you may need to hire
extra staff to manage and administer the system, as well
as incur costs associated with annual external audits/
recertifications.
We have already looked at some typical sources of costs
in relation to health and safety accidents. Benefits can be
along similar lines (removing a current source of cost is, of
course, a future saving, i.e. a benefit of implementing a risk
control measure).
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Factors to be Taken Into Account When Selecting Risk
Controls
Benefits may arise from issues such as:
• Projected reduction in accidents, with associated
savings from less time off and fewer investigations, etc.
• Projected reduction in civil claims.
• Projected reduction in insurance premiums (or bucking
the trend of increases due to repeated claims).
• Increased productivity (i.e. reduced cost per unit). This
may seem difficult to quantify. However, think about
how much time might be saved and translate this to
man-hours. This will give an indication of how much
time, and therefore money, may be saved.
There is obviously a cost implication from controlling
any kind of risk. Costs from implementing safety
improvement measures (some of which may have ongoing as well as one-off costs) can arise from the following
areas:
You must be prepared to provide and justify estimates of
the benefits that you perceive. You will need to analyse
your annual accident statistics and consult with your
human resources, legal and finance departments to arrive
at estimates for some of these benefits.
• Organisational
These are the costs of any new personnel (salary and
training) or perhaps making greater use of an existing
resource required to implement and maintain risk
control measures. There will also be costs associated
with disruption to normal working (temporary staff to
cover workers being trained or overtime).
Initially, you should try to stick to costs and benefits for
which you can provide plausible estimates. The more
intangible elements for which no financial estimate can
be agreed are of more persuasive value. Once you have
estimated costs and benefits, you can calculate a projected
payback or break-even point. The shorter this is the
better, of course, but some projects are more long term.
Even so, do not expect to be greeted with enthusiasm if
your projected payback period is much over three years;
short payback periods are much more attractive to senior
management.
• Design
Reduction of accidents will involve engineering aspects,
such as the purchase, fabrication and installation of
safety devices, other equipment and any associated
software. Safety systems need to be designed, and
programmes for recording and costing losses will
have to be tried out. Costs may also arise from lost
production and sales, perhaps due to plant shut-down
while equipment is being installed.
• Planning
New safe methods of work, permit-to-work schemes
and factory layouts could be considered here.
• Operational
Consideration must be given to the costs of running
and maintaining safety systems, maintaining guards,
interlocks and software (support, licence renewals),
providing PPE as well as carrying out sampling and
testing.
REVISION QUESTIONS
2. List the factors that should be considered when
choosing control measures.
3. Give three reasons why cost-benefit analysis is
not as simple as adding up all the benefits of a
health and safety programme and subtracting
the costs.
(Suggested Answers are at the end.)
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Safe Systems of Work and Permit-to-Work Systems
KEY INFORMATION
• A safe system of work is devised from a risk assessment of the task.
• The following need to be considered when devising a safe system of work:
–– People.
–– Equipment.
–– Materials.
–– Environment.
• A permit to work is a formal written document of authority to undertake a specific procedure and is designed to
protect personnel working in especially hazardous areas or activities. It details the:
––
––
––
––
––
Task.
Significant hazards.
Control measures to be used before work starts and during work.
Checks to establish normal work can resume.
Persons authorised to undertake the task and those responsible for monitoring it.
SAFE SYSTEMS OF WORK
GLOSSARY
SAFE SYSTEM OF WORK
A safe system of work is one where the work is
organised in a logical and methodical manner so as
to remove the hazards or minimise the risks and can
be defined as follows:
A good working definition is that from the UK HSE
leaflet, INDG76L, Safe Systems of Work:
“A safe system of work is a formal procedure which
results from systematic examination of a task in
order to identify all the hazards. It defines safe
methods to ensure that hazards are eliminated or
risks minimised.”
Legal and Practical Requirements
For example, Article 10 of the ILO Occupational Safety
and Health Recommendation (R164) states the
following obligation on employers:
“to provide and maintain workplaces, machinery and
equipment, and use work methods, which are as safe
and without risk to health as is reasonably practicable”.
Copyright © International Labour Organisation 1981
The term “reasonably practicable” occurs quite often in
ILO documents. It is used in a number of legislative systems
throughout the world to qualify legal duties. You may
already be familiar with its meaning. It generally implies
that you can take account of the cost (in terms of time,
money or trouble) in proportion to the magnitude of the
risk in deciding whether you have done enough, or should
do more to control the risk. So if the risk is insignificant in
proportion to the effort required to reduce it, then you
wouldn’t normally be expected to take further action. It is
important to realise that we are not talking about absolute
cost here; it is the cost in relation to the risk. So, big risks
would necessarily entail considerably more effort.
In some countries (like the UK) there is an explicit
legal requirement to maintain systems of work that are
safe. Article 7 of the ILO Safety and Health in Mines
Convention (C176) explicitly mentions the use of
safe systems of work. Even if it is not an explicit legal
requirement in your country, it is almost certainly strongly
implied.
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Safe Systems of Work and Permit-to-Work Systems
Practical Requirements
In developing a practical safe working system, adequate
provision must be made for:
• Safe design of plant and equipment.
• Safe installation of plant and machinery.
• Safe maintenance of plant, equipment and premises.
• Safe use of plant, equipment and tools, through proper
training and supervision.
• Documented, planned maintenance procedures.
• Safe working environment (ventilation, heat and light).
• Adequate and competent supervision.
Job safety training is also an integral part of the safe
working system; there must be a basic commitment to
provide high standards of safety training for all operatives,
new entrants, line managers and the safety practitioner
and safety representatives.
When is a Safe System Required?
• Trained and competent workers.
• Proper enforcement of the safety policy and associated
rules.
• Adequate personal protection for vulnerable workers.
• Documented procedures for the issue of protective
clothing.
• Dissemination of health and safety information to all
the workers.
• Regular reviews (not less than once a year) of all job
safety instructions and methods of work to ensure that:
––
––
––
––
––
––
––
Safe systems of work should fully identify and document all
the hazards, safety precautions and safe working practices
associated with all activities performed by workers. The
analysis should be capable of identifying any unsafe work
methods. There must also be a system of monitoring safety
performance and for publishing information about such
performance.
There is continued compliance with legislation.
Plant modifications are taken into account.
Substituted materials are taken into account.
New work methods are incorporated.
Systems still work safely in practice.
Advances in new technology are exploited.
Safety precautions are adjusted to take into account
accident experience.
Many hazards are clearly recognisable and can be
overcome by physically separating people from them, e.g.
by using guarding on machinery.
A safe system of work is needed when hazards cannot be
physically eliminated and some element of risk remains.
You should apply these principles to routine work as well as
to more special cases such as:
• Cleaning and maintenance operations.
• Making changes to work layouts, materials used or
working methods.
• Employees working away from base or working alone.
• Breakdowns or emergencies.
• Controlling activities of contractors on your premises.
• Loading, unloading and movement of vehicles.
Components of a Safe System of Work
A safe system of work constitutes the bringing together of:
• People.
• Equipment.
• Materials.
• Environment.
Systems of work must have a logical, well thought-out
approach when compared with methods of working,
which often merely evolve over time. In a system of work,
there is a logical progression, from hazard identification
and prediction, so that such hazards are eliminated or
controlled.
There should be a safe system of working for a lone worker
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Safe Systems of Work and Permit-to-Work Systems
USE OF RISK ASSESSMENT IN DEVELOPING
AND IMPLEMENTING A SAFE SYSTEM OF
WORK
Systematic methodologies such as task (or hazard) analysis
can be used to develop a safe system of work. One method
is to use the following four-step approach.
Analysing the Task - Identifying the
Hazards and Assessing the Risks
Assess all aspects of the task and the risks which it presents,
considering hazards to health as well as to safety.
Take account of:
• What is used, e.g. the plant and substances, potential
failures of machinery, toxic hazards, electrical hazards,
design limits, risk of inadvertently operating automatic
controls.
• Who does what, e.g. delegation, training, foreseeable
human errors, short cuts, ability to cope in an
emergency.
• Where the task is carried out, e.g. hazards in the
workplace, problems caused by weather conditions or
lighting, hazards from adjacent areas or contractors,
etc.
• How the task is done, e.g. the procedures, potential
failures in work methods, lack of foresight of infrequent
events.
Involve the people who will be doing the work. Their
practical knowledge of problems can help avoid unusual
risks and prevent false assumptions being made at this
stage.
In those special cases where a permit-to-work system
is necessary, there should be a properly documented
procedure. We shall look at permits to work in detail later
in this element.
Instructing and Training People in the
Operation of the System
Your safe system of work must be communicated properly,
understood by employees and applied correctly. They
should be aware of your commitment to reduce accidents
by using safe systems of work.
Ensure that supervisors know they should implement
and maintain those systems of work and that employees,
supervisors and managers are all trained in the necessary
skills and are fully aware of potential risks and the
precautions they must adopt.
Stress the need to avoid short cuts. It should be part
of a system of work to stop work when faced with an
unexpected problem until a safe solution can be found.
Monitoring and Reviewing the System
Monitoring and reviewing involves periodically checking
that:
Where possible, you should eliminate the hazards and
reduce the risks before you rely upon a safe system of
work.
• Workers continue to find the system workable.
Introducing Controls and Formulating
Procedures
• Any changes in circumstances which require alterations
to the system of work are taken into account and
implemented.
• The procedures laid down in your system of work are
being carried out and are effective.
Control selection may be from the range we identified
earlier (technical, procedural, behavioural), taking account
of the application hierarchy and the general principles of
prevention. Your safe system of work may include verbal
instructions, a simple written procedure or, in exceptional
cases, a formal permit-to-work scheme. Other matters
include:
• Consider the preparation and authorisation needed at
the start of the job.
• Ensure clear planning of job sequences.
• Specify safe work methods.
• Include means of access and escape if relevant.
• Consider the tasks of dismantling, disposal, etc. at the
end of the job.
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Safe Systems of Work and Permit-to-Work Systems
PERMIT-TO-WORK SYSTEMS
TOPIC FOCUS
GLOSSARY
A permit to work has four main sections:
PERMIT TO WORK
A formal written document of authority to
undertake a specific procedure, designed to protect
personnel working in hazardous areas or activities.
Permits are used for high-risk activities that require
complex precautions and clear communication of
additional controls. They are also frequently used
where operations are non-routine, or if new hazards
are introduced and require communication.
MORE…
The UK HSE’s booklet HSG250 Guidance
on permit-to-work systems – A guide for the
petroleum, chemical and allied industries contains
useful guidance in this area and is recommended
reading.
You can access it at:
www.hse.gov.uk/pubns/priced/hsg250.pdf
Need for Permit-to-Work Systems
In many cases, it is impossible, or extremely unrealistic,
to eliminate a risk totally. Even when the risk has been
reduced, we are left with no alternative but to train
someone in the skill to recognise the risks involved, and
the knowledge of how to minimise them; and then, in
effect, say: “Be careful”. A procedural way of taking every
precaution possible is to have a permit-to-work system.
Permit-to-work systems are only as good as those who
design, implement and monitor them and so may be
relatively easy to defeat.
• Issue – the controls that must be implemented
for the work to take place are defined. The
permit is issued by an authorised person.
• Receipt – the workers sign onto the permit to
signal that they accept the conditions of the
permit and understand the hazards and control
measures detailed in it.
• Clearance/Return to service – once the work
is complete, the workers sign to say they have
finished and are leaving the jobsite to allow
normal work to resume, usually also indicating
whether the work is complete or not.
• Cancellation – control of the work area is
accepted back by the issuer and the permit
is cancelled. Extensions may be granted if
additional time is required to complete the work.
Permit-to-work systems are only as good as those who
design, implement and monitor them and so may be
relatively easy to defeat.
When designing a permit-to-work system it is essential that
the company culture is established to support the system.
For a permit system to be worthwhile, there needs to be
an appropriate level of detail within the system, as well
as a commitment to train permit-issuers and ensure that
only authorised persons issue the permit. It must also be
accepted that a good permit will take a little time to issue.
Let us look at a permit-to-work system as an example of a
systematic means of controlling risk.
Whenever maintenance or other temporary work of a
potentially hazardous nature is to be carried out within the
plant, some sort of permit-to-work system is essential.
Jobs likely to require a permit-to-work system include:
• Working in confined spaces.
HINTS AND TIPS
Do not mistake a “permit-to-work system” for a
“safe system of work”. Rather, a safe system of work
may require a permit-to-work system to be adopted
as part of its overall systematic control of risk. The
safe system of work should in itself be considered
as part of the quality control procedures of an
organisation.
© RRC International
• Hot work on plant containing flammable dusts, liquids,
gases or their residues.
• Cutting into pipework containing hazardous
substances.
• Work on electrical equipment.
Most accidents can be attributed in one way or another
to human error. To achieve a high degree of safety we
have to eliminate human error as much as possible by
using a system which requires formal action. Permit-towork systems try to ensure that formal action is taken by
providing a written and signed statement to the effect
that all the necessary actions have been taken. The permit
must be in the possession of the person in charge of the
operation before work begins.
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Safe Systems of Work and Permit-to-Work Systems
Ideally, the control of permit-to-work systems throughout
the company should be the overall responsibility of one
person. That person should appreciate the existence of
hazards and know how to eliminate them. He/she must
have the necessary authority to instruct responsible people
in the organisation to make safety recommendations on
matters requiring their specialist knowledge.
The person responsible must also have authority to
co-ordinate the efforts of everyone concerned with
the provision of safe working conditions. If a permit is
issued, he or she must make sure that everyone involved
understands the terms of the permit and follows its
instructions down to the smallest detail.
Initial Steps
Before work begins, the following general safety
precautions should be observed where applicable:
• Electrical or mechanical isolation of the plant.
• Isolation of the machine or equipment area.
• Locking or blanking off of water, steam, acid, gas,
solvent, and compressed air supplies.
• Erection of scaffolding.
• Provision of temporary guards (or other like
equipment) to make the job safe.
These provisions should be extended to any outside
contractors taking part and it must be made clear that
their workers must not in any circumstances begin work
until the safety precautions and procedures have been fully
explained to them.
Cutting with an oxyacetylene torch requires a permit to work
Essential Features of a Permit-to-Work
System
Permits should:
• Define the work to be done.
• Say how to make the work area safe.
• Identify any remaining hazards and the precautions to
be taken.
• Describe checks to be carried out before normal work
can be resumed.
• Name the person responsible for controlling the job.
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Safe Systems of Work and Permit-to-Work Systems
Details of Permit Form Design
The permit to work should include the following basic
elements:
1.
Permit title
2.
Permit number
Reference to other relevant permits or isolation certificates.
3
Job location.
4.
Plant identification.
5.
Description of work to be done and its limitations.
6.
Hazard identification - including residual hazards and hazards introduced by the work.
7.
Precautions necessary. Person(s) who carries out precautions, e.g. isolations, should sign that precautions have been taken.
8.
Protective equipment.
9.
Authorisation. Signature confirming that isolations have been made, and precautions taken, except those which can only be
taken during the work. Date and time duration of the permit.
10.
Acceptance. Signature confirming understanding of work to be done, hazards involved and precautions required. Also
confirming permit information has been explained to all workers involved.
11.
Extension/shift hand-over procedures. Signatures confirming checks made that plant remains safe to be worked upon, and new
acceptor/workers made fully aware of hazards and precautions. New time expiry given.
12.
Hand-back. Signed by acceptor certifying work completed. Signed by issuer certifying work completed and plant ready for
testing and recommissioning.
13.
Cancellation. Certifying work tested and plant satisfactorily recommissioned.
A Formal Document
The permit to work is always based on a formal document,
the format and details of which will vary according to
circumstances (see following example).
In addition to the safeguards outlined above, the specific
safety precautions to be taken should be itemised. The
document should be valid only for a limited period
depending on the nature of the work and associated
hazards.
© RRC International
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Safe Systems of Work and Permit-to-Work Systems
HEPWORTH BUILDING PRODUCTS LIMITED
PERMIT TO WORK
1.
ISSUE
To
In the employ of
For the following work to be carried out:
I hereby declare that it is safe to work on the following apparatus and that the safety measures detailed below have been carried out.
Here state apparatus on which it is safe to work
ALL OTHER PARTS ARE DANGEROUS
Here state exactly at what points isolating steam, water, air, gas valves, or radioactive shutters have been shut and locked off and what
motors have been locked off and isolated.
Signed
Being the Senior Authorised Person
Date
Time
Note: After being signed for the work to proceed, the receipt must be signed by, and The Permit retained by the person in charge of the
work until the work is suspended or completed.
RECEIPT
2.
I hereby declare that I understand that the plant specified on this permit is safe to work upon and that this Permit applies to this plant
only.
Signed
being the person in charge of the work on the apparatus upon which it is safe to work
Date
Time
Note: The apparatus mentioned must not be recommissioned until this clearance has been signed and The Permit returned by the
person in charge of the work and cancelled.
3.
CLEARANCE
I hereby declare that all men under my charge have been withdrawn and warned that it is no longer safe to work on the apparatus
specified in this permit and that all gear and tools are clear and that all guards have been replaced.
Signed
Being the person in charge of the work
Time
Date
4.
CANCELLATION
I hereby declare that this Permit and all copies of it are cancelled.
Signed
Being the Senior Authorised Person
Time
Date
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Safe Systems of Work and Permit-to-Work Systems
All the methods to be used and precautions to be taken
should be:
• Carefully discussed and agreed beforehand.
• Clearly stated on the permit.
The number of permits issued should be kept to the
minimum required for conducive to the efficient manning
of the plant.
Basic Principles of Operation
TOPIC FOCUS
Certain principles need to be observed for the operation of an effective permit-to-work system.
• Hazard Evaluation
This involves recognising every type of hazard which may be encountered, and then working out the means of
eliminating or overcoming them. The best way of doing this in the long term is by introducing a hazard appraisal
programme, which can be used to formulate a long-lasting system of precautions. A major problem may be that
work is often performed under emergency conditions and there is little time available for a detailed appraisal to
be made.
• Precaution Planning
All planning associated with the permit must be carried out by a competent person who should have sufficient
detailed knowledge of the hazards of the process or plant so that he can formulate the plan properly. The person
must have the necessary position of authority for his or her instructions to be recognised and complied with. He/
she should also have an adequate knowledge of the legal requirements, and of technical terms such as ‘isolate’,
‘lock off’, and ‘blank off’, as they apply to the permit-to-work system.
• Instructing the Supervisors
Those people responsible for the work should be carefully briefed by the person issuing the permit. The
instructions in the permit must be fully understood, and this is best achieved by direct questions and answers to
supplement the written word.
• Issuing the Permit
The permit, which should be completed and signed by the issuer, must be given to the person in charge of the
work (who signs for it). Sufficient copies must also be given to plant or site management and supervisory staff
who may be involved, especially where they need to be kept informed of work progress. An additional copy of
the permit should be exhibited nearby during the time it remains in force.
• Monitoring the Permit
A permit-to-work system is only as good as the people who design, implement and monitor its application and
so can be easy to defeat. Monitoring is therefore a crucial element. The initial explosion and resulting fire in the
Piper Alpha disaster of 1988 in the North Sea was caused by poor adherence to a permit-to-work system. Regular
monitoring is essential to ensure:
–– Full and accurate completion of the documentation, including signing off.
–– That the safe work practices specified in the permit are complied with.
© RRC International
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Safe Systems of Work and Permit-to-Work Systems
General Application
Radiation Hazards
Here are some examples of the types of hazardous
situations in which permit-to-work systems should be used.
Work with radiation may require that a permit-to-work
system is operated to prevent the ingestion, inhalation,
or other absorption of radioactive material into the
body. There is a general duty on employers to restrict
the exposure of workers and other people who could
be affected by contamination. Restriction of exposure
is achieved by engineering controls, design and safety
features.
Electrical Equipment and Supplies
There is considerable evidence that the hazards associated
with electricity are either not understood, or are treated
in too casual a manner. Because of the high level of
risk involved and the serious consequence of switching
errors and other careless mistakes, it is essential that
a comprehensive safety system is put into operation
whenever work is to be started on high voltage equipment.
Any work on substation equipment must be covered by a
permit-to-work system if safe working conditions are to be
ensured and any electrical work should only be carried out
by a qualified electrician.
Confined Spaces
Work in confined spaces introduces risks such as
asphyxiation from gas, fume, or vapour and the necessary
precautions should be included in the permit to work.
Machinery
The biggest risk to maintenance workers is that they
may be injured if machinery is started up while work is in
progress. This is often because the men carrying out the
maintenance work are hidden from the sight of persons
at the plant controls. The machines may be started as a
result of some misunderstanding, negligence, or lack of
knowledge and, unless the motive power is isolated and
cannot be reconnected without specific authority, an
accident might easily occur.
Sewer entry would be considered confined space entry
Overhead Travelling Cranes
If a person is working on or near the crane track, he is likely
to be struck by the crane if effective measures are not
taken to ensure that the crane cannot approach too close
to the working place. In such circumstances a permit-towork system is the only real safeguard.
Chemical Plant
Under normal operating conditions, chemical plant is
designed to work safely. During maintenance, repair or
sometimes commissioning conditions, however, hazards
may be introduced, or work may have to be carried out
which could expose the workers to danger unless carefully
planned safety procedures are adopted.
Each job would have to be considered individually, because
the hazards likely to be encountered (involving flammable,
toxic and corrosive liquids or gases, and explosive
atmospheres) vary considerably.
Formulating a permit-to-work system in a chemical plant
demands a wide technical knowledge and a high degree of
authority on the part of the person issuing the permit. It
is likely, therefore, that only a few specialist managers will
possess the necessary competence.
REVISION QUESTIONS
4. Explain how risk assessment should be used to
develop a safe system of work.
5. What is a permit to work?
(Suggested Answers are at the end.)
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Summary
SUMMARY
Common Risk Management Strategies
We identified and discussed:
• Avoidance or elimination.
• Reduction.
• Transfer.
• Retention with/without knowledge.
Factors to be Taken Into Account When Selecting Risk Controls
Control measures can be considered using the following principles:
• Avoid risks.
• Evaluate.
• Combat at source.
• Adapt work to the individual - ergonomics.
• Adapt to technical progress.
Control measures may be classified as being technical, procedural or behavioural.
The choice of control measures adopted should take account of:
• Use in the long or short term.
• Applicability.
• Practicability.
• Cost.
• Effectiveness.
• Legal requirements.
• Competence/training needs.
Cost-benefit analysis involves ensuring that the cost of risk management is not disproportionate to the savings by
reduction of losses.
Costs of controlling risks include: organisational, design, planning, and operational costs.
Safe Systems of Work and Permit-to-Work Systems
We considered the following in terms of safe systems of work:
• A safe system of work is one where the work is organised to remove hazards and minimise risks.
• It should proceed logically from identification to elimination of risks.
• A safe system of work is needed where hazards cannot be physically eliminated.
• Four steps to identifying a safe system of work:
–– Analyse the task - identifying hazards and assessing risks.
–– Introduce controls and formulate procedures.
–– Instruct and train people in the operation of the system.
–– Monitor and review.
A permit to work is a formal written document of authority to undertake a specific procedure and is designed to
protect personnel working in hazardous areas or activities.
Permit-to-work systems do not replace safe systems of work; they try to ensure that formal action is taken to
eliminate human error.
© RRC International
Unit IA – Element IA5: Risk Control
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Exam Skills
QUESTION
The last question you attempted looked daunting but hopefully you will feel more confident at tackling this one.
Here we will have a look at another of the short answer, compulsory 10 mark questions.
Remember that with these Section A questions you have no choice. You need to average 50% across the six
compulsory questions to give yourself a great chance of passing the exam. Most students find that there are
questions they find easy to answer and others where their knowledge is weaker. You need to develop your skills and
knowledge to raise your marks in your weaker questions, so make sure you have a go at all of them.
Question
A maintenance worker was asphyxiated when working in an empty fuel tank. A subsequent investigation found that
the worker had been operating without a permit to work.
(a) Outline why a permit to work would be considered necessary in these circumstances.
(b) Outline the possible reasons why the permit-to-work procedure was not followed on this occasion.
(3)
(7)
APPROACHING THE QUESTION
SUGGESTED ANSWER OUTLINE
Note that your answer to this question will need to show
a logical progression of ideas and both sections require an
outline; think about the marks on offer for both parts of
the question.
(a) A permit to work would be considered necessary in
these circumstances because:
–– Risk assessment of the work identified its need.
–– It is a high risk task in a confined space.
–– Additional hazards might develop as the work
progresses therefore the job needs a structured
approach.
–– A permit to work for this type of work could be a
legal or national requirement.
(b) Possible reasons why the permit-to-work procedure
was not followed on this occasion include:
–– There was no permit-to-work system available.
–– The initial risk assessment was inadequate and
therefore the potential hazards were not fully
understood or identified.
–– The organisation had a poor health and safety
culture and therefore violations of work systems
and permits to work were routine.
–– The permit system was thought to be too
bureaucratic and complicated.
–– There was pressure to complete the work quickly
and following the permit prevented this.
–– There was difficulty organising controls before
starting work due to lack of a competent person to
authorise the permit.
–– The controls to be followed were not clear or
specific.
–– Management failed to stress the importance of
using a permit in such circumstances and did not
communicate this to workers.
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Exam Skills
POSSIBLE ANSWER BY EXAM CANDIDATE
(a) A risk assessment of the job could have identified the need for a permit to work. The work is in a confined space
therefore a permit would be needed.
(b) The permit system was too complicated and prevented the job being finished quickly. The control measures
needed were not described clearly or specifically and were difficult to organise. There was no competent person to
authorise the permit. Management did not stress the importance of using a permit for this type of work or had not
even introduced a permit-to-work system.
REASONS FOR POOR MARKS ACHIEVED BY CANDIDATES IN EXAM
An exam candidate answering this question would achieve poor marks for:
• Outlining what should be included in a permit to work rather than why it was necessary for the circumstances given.
• Simply listing the operations where a permit would be required rather than outlining its need.
• Listing possibilities for the permit not to be followed instead of giving a fuller outline with reasons.
© RRC International
Unit IA – Element IA5: Risk Control
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v2.1
ELEMENT
ORGANISATIONAL FACTORS
6
LEARNING OUTCOMES
On completion of this element, you should
be able to demonstrate understanding
of the content through the application
of knowledge to familiar and unfamiliar
situations and the critical analysis and
evaluation of information presented in
both quantitative and qualitative forms. In
particular you should be able to:

Explain
the internal and external influences on health
and safety in an organisation.
the different types of organisation,
Outline
their structure, function and the concept of the
organisation as a system.

Identify
the various categories of third parties in a
workplace, the relevant duties, responsibilities and
controls.
the role, influences on and procedures for
Explain
formal and informal consultation with employees in
the workplace.
the development of a health and safety
Outline
management information system, the relevant duties
and the data it should contain.

Explain
health and safety culture and climate.
the factors which can both positively and
Outline
negatively affect health and safety culture and
climate.
© RRC International
Unit IA – Element IA6: Organisational Factors
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| 6-1
Contents
INTERNAL AND EXTERNAL INFLUENCES
Internal Influences on Health and Safety Within an Organisation
External Influences on Health and Safety Within an Organisation
Revision Questions
6-3
6-3
6-5
6-6
TYPES OF ORGANISATIONS
Concept of the Organisation as a System
Organisational Structures and Functions
Organisational Goals and Those of the Individual: Potential Conflict
Revision Question
6-7
6-7
6-7
6-11
6-12
THIRD PARTY CONTROL
Integration of Goals of the Organisation with the Needs of the Individual
Identification of Third Parties
Reasons for Ensuring Third Parties are Covered by Health and Safety Management Systems
Basic Duties Owed To and By Third Parties
Selection, Appointment and Control of Contractors
Responsibilities for Control of Risk Associated with Contractors on Site
Revision Questions
6-12
6-12
6-13
6-13
6-14
6-15
6-16
6-16
CONSULTATION WITH WORKERS
Provision of Information Relating to Hazards/Risks to Third Parties
Role of Consultation Within the Workplace
Formal Consultation
Informal Consultation
Role of the Health and Safety Practitioner in the Consultative Process
Behavioural Aspects Associated with Consultation
Development of Positive Consultative Processes
Revision Questions
6-16
6-16
6-17
6-18
6-19
6-20
6-20
6-21
6-22
HEALTH AND SAFETY MANAGEMENT INFORMATION SYSTEM
Health and Safety Management Information Systems Within the Workplace
Types of Data Within a Health and Safety Management Information System
Requirements and Practical Arrangements for Providing Health and Safety Information
Revision Questions
6-23
6-23
6-24
6-25
6-25
HEALTH AND SAFETY CULTURE AND CLIMATE
Culture and Climate
Impact of Organisational Cultural Factors on Individual Behaviour
Indicators of Culture
Correlation Between Health and Safety Culture/Climate and Health and Safety Performance
Measurement of the Culture and Climate
Revision Questions
6-26
6-26
6-27
6-28
6-28
6-28
6-30
FACTORS AFFECTING HEALTH AND SAFETY CULTURE AND CLIMATE
Promoting a Positive Health and Safety Culture
Factors that May Promote a Negative Health and Safety Culture or Climate
Effecting Cultural or Climate Change
Problems and Pitfalls Relating to Change
Revision Questions
6-31
6-31
6-32
6-33
6-35
6-35
SUMMARY
6-36
EXAM SKILLS
6-38
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Internal and External Influences
KEY INFORMATION
• The key internal influences on health and safety are:
–– Finance.
–– Production targets.
–– Trade unions.
–– Organisational goals and culture.
• The key external influences are:
––
––
––
––
––
––
––
––
Legislation.
Enforcement agencies.
Courts and tribunals.
Contracts.
Clients and contractors.
Trade unions.
Insurance companies.
Public opinion.
INTERNAL INFLUENCES ON HEALTH AND
SAFETY WITHIN AN ORGANISATION
• Pay incentive bonuses to increase the daily rate of
production.
Finance
• Reduce the quality of the goods by using inferior
materials.
Health and safety costs money to administer, but it costs
considerably more if you don’t invest in health and safety
(remember Elements IA1 – costs of accidents, and IA5 –
cost-benefit analysis).
Annual budgets are set which allow you to plan. Be careful
that the safety budget is not diverted to more ‘urgent’
projects. In difficult years, money available for hiring
resources, maintaining safety equipment/systems and
safety improvements is more limited (especially if the
benefits are not immediate). Some things will just not
get done which will inevitably lead to accidents/ill health
which will lead to yet more costs. Small companies may fail
as a result of a compensation claim arising from just one
accident.
Production Targets
Achieving production goals can put intense pressures
on workers leading to stress and an increase in incidents
and accidents in the workplace. It is recognised that
increased competition, longer hours, increased workloads,
new technology and new work patterns are significant
occupational stressors. Industrial psychology also requires
that in a ‘conveyor-type’ operation, the speed of the belt
should be geared to the capacity of the slowest operator.
The pressures on management to achieve production
targets/increase production can be translated into action
on the shop-floor in a number of ways:
Apart from increasing the size of the workforce, these
measures encourage workers to ‘cut corners’. For example:
• Longer hours can lead to tiredness and less attention to
safety factors.
• Bonuses for increased production can lead to disregard
for any safe systems of work which slow down the
speed at which the worker can operate.
• Increased production targets may create anxiety in the
slower worker, especially if part of a team, and can lead
to short-cuts being taken in an effort to keep up with
colleagues.
• Reducing quality may require new systems of work,
leading to stress.
All of these can lead to unsafe acts which may have
considerable effect on the company’s health, safety and
accident record.
• Make the workforce work longer hours.
• Increase the size of the existing workforce.
© RRC International
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Internal and External Influences
Trade Unions
Trade union safety representatives may be involved as
members of safety committees, and as such are actively
involved in improving health and safety in the workplace.
They have a dual role in that they can be involved in
the formulation of policy in certain companies, but
they also have a policing role in that they can monitor
management’s performance. They carry out the following
functions:
• Investigating potential hazards and dangerous
occurrences.
• Examining the cause of accidents.
• Investigating health and safety complaints from
workers they represent.
• Making representations to the employer on
complaints, hazards and accidents.
• Carrying out inspections of the workplace.
• Consulting with enforcement agency inspectors on
behalf of the workers they represent.
• Receiving certain information from the enforcement
agency inspector.
In many workplaces, this type of representation is not
restricted to trade union representatives, but has been
widened to include elected workers who are not members
of a trade union.
Organisational Goals and Culture
The goals and culture of the organisation strongly
characterise the company. Some organisations rate safety
highly and treat it seriously, not only in what they claim to
do (their safety policy), but also in what actually happens
in practice. Safety culture can be simply described as “the
way we do things”. If you have worked for several different
organisations you will probably recognise different cultures
in terms of what they accept and tolerate. We will look at
this topic in more detail later in this element.
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Internal and External Influences
EXTERNAL INFLUENCES ON HEALTH AND
SAFETY WITHIN AN ORGANISATION
Enforcement Agencies
Courts/Tribunals
Insurance Companies
Contracts/Contractors/Clients
The Organisation
Legislation
Trade Unions
Public Opinion
External influences on the organisation
Legislation
Contracts/Contractors/Clients
Any company or officers of a company ignore legislation
at their peril. Changes in legislation are well-publicised in
relevant journals and any health and safety adviser should
ensure that he/she is aware of any pending changes and
their effect on the company.
The nature of contracts and relationships with contractors
may have profound effects on the health and safety
of a particular contract. Contracts must, of course, be
honoured and be fair (they are usually enforceable through
the courts). Contractors may expose the company to many
additional hazards and liabilities (and vice versa). In those
circumstances where a contractor feels that he is making a
loss on a particular job, there may be a strong temptation
to cut corners and perhaps compromise health and safety.
Where a client takes a direct interest in the progress of a
contract and in achieving good standards of health and
safety, the standards on site are positively improved. There
is a need for effective vetting of contractors’ own company
health and safety competence before awarding the
contract to them.
Tribunals/Courts
Court decisions clearly have a direct effect on the company
concerned, but may also create precedents that are legally
binding on all companies in similar circumstances.
Enforcement Agencies
In some countries there may be enforcement agencies for
local legislation who can influence health and safety within
companies by:
• Providing advice on general legal requirements.
• Serving enforcement notices in cases of specific legal
contraventions.
• Prosecuting employers for serious breaches of the law.
Trade Unions
Trade unions are active in many countries promoting
standards of health and safety in a variety of ways:
• Supporting their members’ legal actions and setting
precedents and standards.
• Acting through lobby and pressure groups to influence
legislation.
• Carrying out and sponsoring research.
• Publicising health and safety matters and court
decisions.
• Providing courses on health and safety subjects.
© RRC International
Unit IA – Element IA6: Organisational Factors
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| 6-5
Internal and External Influences
Insurance Companies
In many countries, employers are legally required to
carry insurance to cover claims for workplace injury/ill
health from their workers. Should a company suffer an
unusually high accident rate, the insurance company can
either increase their insurance premiums, or insist that the
company adopt risk reduction measures. It is now more
common for insurance companies to carry out their own
inspections of workplace risks and set certain minimum
standards.
Public Opinion
Public opinion can have a powerful effect on legislators,
which may result in legislation being passed, or prosecution
taking place. Other actions may involve a particular
company’s products being deliberately boycotted by
consumers because of the company’s behaviour, or other
more direct forms of action by protesting consumer
groups.
REVISION QUESTIONS
1. List some of the internal influences on an
organisation in respect of health and safety at
work.
2. List some external bodies which can influence
health and safety standards of organisations,
identifying the means by which each body exerts
its influence.
(Suggested Answers are at the end.)
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Types of Organisations
KEY INFORMATION
• An organisation may be considered to be a system that has interacting components forming a whole.
• Within an organisation there are both formal and informal structures.
• Conflict may arise as a result of individual goals not being consistent with those of the organisation.
CONCEPT OF THE ORGANISATION AS A
SYSTEM
ORGANISATIONAL STRUCTURES AND
FUNCTIONS
GLOSSARY
GLOSSARY
SYSTEM
ORGANISATION
A regularly interacting or interdependent group of
items forming a united whole.
A group of persons who interact with each other in
an effort to achieve certain predetermined goals or
objectives.
(Note: This is one of several definitions which can be
applied to “systems”.)
The systems approach to management is a way of thinking
in which the organisation is viewed as an integrated
complex of interdependent parts that are capable of
sensitive and accurate interaction among themselves and
within their environment.
Common characteristics of systems are that:
• Every system is part of a still larger system and, itself,
encompasses many subsystems (‘circles within circles’).
• Every system has a specific purpose to which all its
parts are designed to contribute.
• A system is complex - any change in one variable will
effect change in others.
• Equilibrium: a system strives to maintain balance
between the various pressures affecting it, internal and
external. Some systems experience more pressures to
change than others, giving rise to stable and unstable
systems.
Initial reaction to pressure is often what is called dynamic
conservatism - the organisation fights like mad to stay
just as it is! However, sooner or later homeostasis takes
place (activities which serve to stabilise and vitalise the
organisation as a whole in an evolving state of dynamic
equilibrium).
© RRC International
At a very basic level, the worker goes to work to earn
money. The earning of money is a specific goal common
to everyone in that particular organisation. There will
be many other shared goals and objectives. There will
also be many goals which are not shared, which lead to
conflict, and which, ultimately, may have a bearing on the
success or failure of the organisation. A work organisation
is an organisation which has been established for a
specific purpose and within which work is carried out
on a regular basis by paid workers. Examples of such are:
businesses, hospitals, educational institutions, government
departments, etc.
Formal and Informal Structures
All organisations have a formal and informal structure.
Within each organisation there is a formal allocation of
work roles and the administrative procedures necessary to
control and integrate work activities.
However, organisations also have an informal arrangement
or power structure based on the behaviour of workers how they behave towards each other and how they react
to management instructions. The foreman or supervisor
will have specific instructions from management aimed
at achieving certain goals or production targets. In many
cases, he ‘adjusts’ those instructions in accordance with
his personal relationships with individual, or groups of,
workers. This takes us some way towards being able
to make a distinction between formal and informal
organisations. There is a blurring at the edges between the
two - a cross-over point where the distinction between the
formal and informal at the actual point of action becomes
obscured and is the subject of a great deal of sociological
argument and discussion. For our purposes, we can
describe or explain them in the following way.
Unit IA – Element IA6: Organisational Factors
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Types of Organisations
• Formal Organisational Structure
Most organisations describe their structure in the
form of an organogram. This shows the reporting
relationships from the chief executive of the company
down to the workers carrying out the most basic tasks.
The following figure illustrates a typical formal
structure for a small company.
DIRECTOR
SALES
MANAGER
PRODUCTION
DIRECTOR
SALES STAFF
PRODUCTION
EMPLOYEES
QUALITY
MANAGER
FINANCE
DIRECTOR
ACCOUNTS
STAFF
Formal structure
In theory, every person within the structure has a
well-defined role with clear lines of reporting and
clear instructions as to standards of performance.
These roles are clearly understood by others in the
organisation so that everyone acts together to achieve
the organisational objectives.
• Informal Organisational Structure
An organisational chart cannot identify all the
interactions which occur between staff. Invariably,
it will be the quality of personal relationships which
determines how communications flow within a
company and ‘how things get done’.
In most organisations, the formal structure represents
the model for interaction, but in reality the informal
relationship is significant in understanding how
organisations work. The informal structure cannot
replace the formal structure, but works within it. It
can influence relationships and effectiveness in both
positive and negative ways. An understanding of it is an
invaluable aid to good management. Take another look
at the Formal Structure figure and then compare it
with the Informal Structure figure that follows. Look
at the superimposed informal structure shown by the
dotted lines.
6-8
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v2.1
Types of Organisations
ER
H
ET
OG
FT
DIRECTOR
BR
OT
OL
YG
LA
P
SALES
MANAGER
HE
WENT TO SAME SCHOOL
PRODUCTION
DIRECTOR
QUALITY
MANAGER
RS
-IN
-LA
W
FINANCE
DIRECTOR
AT UNIVERSITY TOGETHER
SALES STAFF
PRODUCTION
ACCOUNTS
STAFF
EMPLOYEES
MEMBERS OF COMPANY SOCCER TEAM
Informal structure
An awareness of these informal relationships would
obviously influence how communications are made.
The effective manager will use such knowledge to
break down resistance to new measures (including
health and safety).
A simple way of making a distinction between formal and
informal organisation structure is:
• Formal - represented by the company organisation
chart, the distribution of legitimate authority, written
management rules and procedures, job descriptions,
etc.
• Informal - represented by individual and group
behaviour.
Organisation Charts
The structure of an organisation is determined by its
general activities - its size, location, business interests,
customer base, etc. and by the way in which its workers are
organised.
The organisational pyramid (Formal Structure) illustrated
earlier is probably the principal model for most
organisations with management at its apex and the
workforce at its base. Within this model each separate
department has its own pyramid with its own power
structure and departmental goals. If the organisation
is very large then considerable problems involving
communication, efficiency, effectiveness, etc. may occur.
The following figures show two typical pyramids.
© RRC International
Unit IA – Element IA6: Organisational Factors
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Types of Organisations
Board of Directors
Head Office
Departments
Accounts
Company
Secretary
Administration
Marketing
Sales
Production
Human
Resources
Typical company pyramid
HEALTH AND SAFETY
DIRECTOR
Security Manager
Health and Safety
Manager
Assistant Security
Manager
Occupational Health
Nurse
Security Officers
Typical departmental pyramid
By looking at these structures you can see the formal levels
of authority and responsibility within the organisation
or department. Basically, authority or control runs from
top to bottom. However, there are other important
management/worker relationships, such as line
management, staff, and functional relationships.
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Types of Organisations
Role of Management
Functional Relationship
GLOSSARY
MANAGE AND MANAGEMENT
To manage is “to organise, regulate and be in charge
of a business…”, and management is “those engaged
in these functions”.
Management will lead through issued instructions, policies
and procedures, and supervision to ensure that these are
being adhered to.
There is normally a line of responsibility with different
functions at each level.
Line Management
Look at the following figure:
In many larger organisations, certain members of staff have
a company-wide remit to carry out activities ‘across the
board’. Human resources departments often implement
company appraisal plans which affect every department;
internal auditors visit all departments to carry out their
work; and quality control inspectors and health and safety
managers have a company-wide role in order to inspect
and check procedures. In such circumstances, any defects
discovered would normally be dealt with by reporting
them to the departmental head rather than dealing directly
with any individual within the department.
The various hierarchies and line, staff and functional
relationships can create huge problems for any
organisation. Office ‘politics’ and protocols often obstruct
communication, which is one of the key factors in efficient
management.
Small Businesses
Works Director
These are organisations with up to 50 workers. A feature
of such organisations is the necessity (certainly in those
with few workers) for those employed to adopt several
roles. Small businesses are far less likely to have a dedicated
health and safety professional than a large organisation; the
role is often taken on by an individual who combines the
responsibility with other tasks.
Works Manager
Foreman
Chargehand
ORGANISATIONAL GOALS AND THOSE OF
THE INDIVIDUAL: POTENTIAL CONFLICT
Shop-Floor Operative
A typical line management function
Here you can see a direct line of authority from the Works
Director to the Shop-Floor Operative.
GLOSSARY
GOAL
In this context, a goal can be defined as “an object of
effort or ambition”.
Staff Relationship
The managing director’s secretary reports to the Managing
Director (MD) and carries out instructions by passing
the MD’s wishes to other directors and senior heads of
department, but there is no ‘line’ relationship between the
secretary and those departments. There is no instruction
from the secretary, as her/his authority stems from the
MD. A health and safety consultant reporting directly to an
MD is not in a position to ‘instruct’ heads of departments
to carry out health and safety policies or instructions.
Again, his/her authority stems from the MD and, in
practice, he/she would advise heads of department of any
changes in policy agreed with and authorised by the MD.
© RRC International
To be successful and progress, both an organisation and
individuals have to have goals. For the organisation, the
goal may be an objective to be the “best in their field”, or
to be the “largest”, or to be renowned for “outstanding
quality”. For the organisation to achieve these goals the
workers need to have their own goals and objectives
to work towards the organisational goal. However, the
individual may have other goals which may or may not
impact on the organisation. For example, an individual may
hope to be promoted, which would probably mean that
they will work very hard to achieve their goals/objectives
within the organisation, as this should help them to achieve
their own personal goal of promotion. Another individual,
however, may want to work less hours, or have more time
with their family, and this may impact negatively on their
willingness to put in extra hours which may be required for
the organisation to achieve its goal.
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Types of Organisations
INTEGRATION OF GOALS OF THE
ORGANISATION WITH THE NEEDS OF THE
INDIVIDUAL
In setting and achieving health and safety targets, the
organisation should consider the needs of the individual.
Where health and safety tasks are delegated, at all
levels from senior managers to shop-floor workers, the
responsible individual(s) should be clearly identified and
stated. This gives ownership to the individual concerned,
and is an important factor in getting the individual to ‘buy
in’ to the organisation’s goals.
Many organisations give responsibility without the relevant
authority - this can be a mistake as, without authority,
the individual can feel frustrated at being unable to carry
out the tasks. This leads to a feeling of futility and results
in tasks being done poorly or not at all. Where authority
is given to enable the individual to carry out tasks, this can
result in an increase in self-esteem and every chance that
the tasks will be performed well.
The limits of responsibility and authority should be clearly
defined so that individuals know the extent of what they
can and cannot do.
With responsibility comes accountability, and this
must be made clear to all individuals given health and
safety responsibilities. One important issue when giving
responsibility is to ensure that the individual is capable of
accepting it.
REVISION QUESTION
3. What is the difference between a formal and
informal organisational structure?
(Suggested Answer is at the end.)
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Third Party Control
KEY INFORMATION
• Third parties include contractors, visitors, trespassers and members of the public.
• There are legal, moral and economic reasons for ensuring that third parties are covered by health and safety
management systems.
• Basic duties owed to and by third parties include those of:
–– Designers, manufacturers and suppliers to customers/users.
–– Occupiers of premises/land to visitors.
–– Contractors to clients and vice versa.
• To ensure that the contractor chosen is capable of doing the work required safely, it is necessary to introduce
procedures for the selection, appointment and control of contractors.
• The responsibility for control of risk associated with contractors on site is shared, the client being responsible for
the workplace, environment and their workers and the contractor being responsible for the job and their workers.
• It is important to provide information relating to hazards/risks to third parties such as contractors, visitors and
the general public.
IDENTIFICATION OF THIRD PARTIES
A third party is defined as: “someone other than the
principals who are involved in a transaction”. In this case, it
means anyone other than the employer, worker or owner
who may be affected by the safety of a workplace.
GLOSSARY
CONTRACTOR
“One who is engaged to perform a certain task
without direction from the person employing him.”
VISITORS AND TRESPASSERS
Visitors are literally third parties who visit premises
or land. Many visitors will either be explicitly invited
or have an implicit right to be there. However, a
trespasser is someone who has no invitation or
consent of any kind (explicit or implicit); in fact their
presence is strongly objected to.
MEMBERS OF THE PUBLIC
Members of the public are not workers or
contractors, but may become visitors or trespassers
if they enter the premises.
Notice how a person can move from one
category to another quite easily depending on the
circumstances.
© RRC International
REASONS FOR ENSURING THIRD PARTIES
ARE COVERED BY HEALTH AND SAFETY
MANAGEMENT SYSTEMS
In terms of potential legal requirements, the ILO
Occupational Safety and Health Convention C155
(Article 17) states:
“Whenever two or more undertakings engage in
activities simultaneously at one workplace, they
shall collaborate in applying the requirements of this
Convention.”
Copyright © International Labour Organisation 1981
The accompanying Recommendation R164 (Article 11)
states:
“Whenever two or more undertakings engage in
activities simultaneously at one workplace, they
should collaborate in applying the provisions regarding
occupational safety and health and the working
environment, without prejudice to the responsibility
of each undertaking for the health and safety of its
employees. In appropriate cases, the competent
authority or authorities should prescribe general
procedures for this collaboration. “
Copyright © International Labour Organisation 1981
So, both of these imply that account is taken of third
parties who happen to be working on the same premises.
This invariably will involve the exchange of information (on
hazards, etc.), as well as the co-ordination of emergency
arrangements and sharing of procedures.
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Third Party Control
This collaboration requirement is repeated in some of the
sector-specific conventions, such as the Safety and Health
in Construction Convention C167 (Article 8), together
with its Recommendation R175 (Article 5).
Even if your country has not ratified the above ILO
convention, you may have equivalent requirements.
It is quite clear that there is a moral imperative which
‘obliges’ us to look after other people, but because of
the complexities of modern society, we often now have
legislation which provides standards by which we look after
the physical well-being of our neighbours - the young, the
elderly, the disadvantaged - physically and mentally, and
the visitor who may enter our premises and workplaces
completely oblivious to the hazards which may lurk there.
Apart from moral and legal obligations to third parties,
there is another consideration, and that is the economic
factor.
What are the economic implications of neglect of health
and safety in the workplace? We have already looked
briefly at the hidden costs of accidents.
Economic considerations are twofold. Accidents resulting
from poor health and safety management result in huge
financial losses to everyone concerned. Poor health and
safety management is often itself caused by the serious
lack of economic resources available for health and safety
purposes both at national and workplace levels.
It is not a difficult management exercise to compare the
costs of preventing accidents with the costs arising from
them (compensation, lost production, increased insurance
premiums, overtime, legal fees, fines, etc.) but the simple
logic appears to escape many boardrooms. Prevention
of accidents and ill health is a worthwhile investment
which attracts enormous dividends both for the individual
employer and the national economy as a whole.
BASIC DUTIES OWED TO AND BY THIRD
PARTIES
You may be familiar with the concept of “duty of care to
your neighbour”. This is quite a common principle in civil
law, even without a specific contract between parties. It
arises from the moral/ethical duty not to cause injury/
damage through negligent (i.e. careless) acts/omissions.
The type of civil action that might arise is called “the tort
of negligence” (a “tort” is a civil wrong).
Designers, Manufacturers, Suppliers to
Customers/Users
This duty is usually in relation to machinery and dangerous
substances for use at work. The duty in relation to
machinery usually encompasses design and construction
(as safe as possible), testing to ensure that they are in fact
reasonably safe, and provision of information to users on
safe use. For example, Article 12 of the ILO Safety and
Health Convention (C155), places a duty on national
governments to create laws which ensure that designers/
manufacturers of machinery, equipment and substances do
just that.
Occupiers of Premises/Land to Visitors
Many countries have established a common duty of care
of an occupier to all lawful visitors (remember the earlier
definition of “visitor”). The duty is essentially to take
reasonable care to see that the visitor will be reasonably
safe in using the premises for the purposes for which they
are invited or permitted by the occupier to be there. The
duty is usually in respect of dangers due to both the state
of the premises, as well as any acts or omissions. It is also
common for this duty (albeit in a qualified, lesser form)
to be extended to trespassers (i.e. those who have no
invitation or permission to be there).
Generally, the occupier must be prepared for children to
be less careful than adults. If the occupier allows a child to
enter premises then the premises must be reasonably safe
for a child of that age. The occupier must be aware of any
lure or attraction to children, such as a pond, that could
constitute a trap.
It is generally accepted that there may be special risks
associated with certain types of work undertaken by the
visitor. In such cases, an occupier may expect that a person,
in doing their job, will appreciate and guard against any
special risks related to it, e.g. if the occupier invites a
competent electrician to do some work, and due to the
carelessness of the contractor he or she is electrocuted,
then the occupier would not generally be liable.
It is common that an occupier can try to discharge at least
some of his duty of care by displaying a warning notice, but
it is not usually enough on its own. Indeed, signs may be of
little use to protect children or the visually impaired.
Earlier, we also looked at Article 17 of C155, the ILO
Occupational Safety and Health Convention, and also
Article 11 of the associated Recommendation R164. These
contained a general duty to collaborate where two or more
employers engage simultaneously in activities at the same
workplace. If your country has ratified the convention,
these requirements will be enshrined in law.
We will now consider some specific examples of
relationships which illustrate typical duties owed to and by
third parties.
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Third Party Control
Contractors to Clients (and Vice Versa)
Choosing a Contractor
It has long been held that professional people owe a duty
of care to their clients, but under the “neighbour” concept,
the reverse is also true. This implies co-ordination/
collaboration of activities and exchange of essential
information that might affect the health and safety of
respective workers (which we have already mentioned
in relation to Article 17 of the ILO Safety and Health
Convention). This is especially true for the client to
provide information on any special site hazards. The
ILO code of practice on Construction Safety and Health
also identifies the responsibility of the client to ensure
that contractors consider the cost of adequate health
and safety provision for the construction project when
tendering for the job, i.e. there is a responsibility not to
just choose contractors based on “lowest bid”, and there
is again an implication that information on specific site
hazards is communicated to the contractor so that he is
able to take account of them when counting the cost of
safety at the tender stage. The client should also ensure
that the contractor is allowed sufficient time for the job, in
consideration of health and safety (i.e. don’t set unrealistic
deadlines which would compromise safety). There is also
an implied duty (frequently enshrined in law) for clients
to make reasonable “due diligence” efforts to ensure that
the contractor that they engage is actually competent to
do the job, and a reciprocal duty on the contractor (as on
any employer/self-employed person) to ensure that his
workers are competent to do the job.
• Determine what technical and safety competence is
required by the contractor.
• Ask the contractor to supply evidence of that
competence.
• Supply information regarding the job and the site,
including site rules and emergency procedures.
• Ask the contractor to provide a safety method
statement outlining how they will carry out the job
safely.
Contractors Working on Site
• Introduce a signing in and out procedure.
• Ensure the contractor provides a named site contact.
• Carry out site induction training for all contractor
workers.
• Where necessary, control activities by using a permitto-work system.
Checking on Performance
• Are contractors working to agreed safety standards?
• Have there been any incidents and were they reported?
• Have there been any changes of circumstance, e.g.
change of personnel?
SELECTION, APPOINTMENT AND CONTROL
OF CONTRACTORS
To ensure that a chosen contractor is capable of doing the
work required safely, you need to introduce procedures
that will identify and cover key points. The following lists
suggest an approach that covers all aspects of contractor
hire (adapted from UK HSE Guidance HSG159, Managing
Contractors).
The Planning Stage
• Define the task(s) that the contractor is required to
carry out.
• Identify foreseeable hazards and assess the risks from
those hazards.
• Introduce suitable control measures to eliminate or
reduce those risks.
• Lay down health and safety conditions specific to the
tasks.
• Involve the potential contractors in discussions
concerning the health and safety requirements.
• Agree realistic timescales for the work.
A client’s project manager monitors the work of a contractor
Review
• Regularly review the procedures to ensure currency and
effectiveness.
Always remember that contractor work can impact on
workers and vice versa. The passing on of information
regarding work that may affect others is a vital part of safe
working with contractors.
• Ensure accident and first-aid procedures and
arrangements are in place.
© RRC International
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Third Party Control
RESPONSIBILITIES FOR CONTROL OF RISK
ASSOCIATED WITH CONTRACTORS ON SITE
It is clear that there is a general duty to ensure that all
reasonably practicable measures are taken by clients (i.e.
those who engage contractors) and people in charge of
premises to reduce the risk to contractors and vice versa.
It is probably fair to say that the responsibility for risk
control is shared - the client being responsible for the
workplace, environment and their workers; the contractor
being responsible for the job and their workers, BUT
there will be many areas of overlap (indeed the terms
of the engagement contract should help clarify major
responsibilities). Tight procedures are required to
ensure all possibilities are addressed. This type of shared
responsibility is exemplified by the provision of site welfare
facilities. The client is often responsible for ensuring that
adequate management arrangements are in place for
the provision of site welfare facilities. The contractor is
responsible for ensuring that welfare facilities are provided
and that adequate site induction is given.
• General Public
Information to the general public will include such
things as notices and warnings on perimeter fences,
gates, etc. Road works and other activities that impact
on the general public, as well as requiring prominent
signage, may be publicised in local newspapers and prework notices erected at the site.
MORE…
You can find further information on contractor
management in the UK HSE publication Using
contractors - A brief guide (INDG368) that you can
download from:
www.hse.gov.uk/
PROVISION OF INFORMATION RELATING TO
HAZARDS/RISKS TO THIRD PARTIES
The provision of information to third parties relating to
hazards and risks is important.
• Contractors
We have already looked at the duty to collaborate
on health and safety matters contained within the
Occupational Safety and Health Convention. This will
necessarily involve exchange of relevant information
(on hazards, risk assessments, method statements,
procedures, etc.). Many items may be specifically
identified in the contract between the two parties.
• Visitors
It is usual to give visitors to the workplace written
information on emergency procedures, often in the
form of a small card or on a visitors’ slip. Think about
where the visitor is going and what the purpose of their
visit is. It may be necessary to supplement the general
information with other, more specific, information
relating to their particular situation.
6-16
REVISION QUESTIONS
4. Outline the legal reasons for ensuring that
third parties are covered by health and safety
management systems.
5. What are the economic implications of neglect
of health and safety in the workplace?
(Suggested Answers are at the end.)
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Consultation with Workers
KEY INFORMATION
• Successful health and safety management depends on a workforce that is committed to health and safety and
which co-operates with the employer. ILO Occupational Safety and Health Convention (C155), Article 20,
and ILO Occupational Safety and Health Recommendation (R164) lay down useful principles regarding
consultation in the workplace.
• Formal consultation will involve worker representatives on health and safety and the safety committee.
• Informal consultation relies on discussion groups, safety circles and departmental meetings.
• The health and safety practitioner has a substantial role to play in the consultative process.
• Behavioural aspects associated with consultation include peer group pressures and identification of potential
areas of conflict.
• Positive consultation is based on a willingness of employer and worker to consider problems together, to make
use of each other’s knowledge.
ROLE OF CONSULTATION WITHIN THE
WORKPLACE
Successful health and safety management depends on
a workforce that is committed to health and safety and
which co-operates with the employer.
The following is from the ILO Encyclopaedia article
Consultation and Information on Health and Safety (Part
III, Chapter 21).
“The idea of employers and employees working jointly
to improve health and safety at work is based on
several principles:
1. Workers can contribute to prevention of industrial
accidents by spotting and warning about potential
hazards and giving notice of imminent dangers.
2. Involving employees educates and motivates them to
co-operate in the promotion of safety.
3. Ideas and experiences of workers are regarded as a
useful contribution to safety improvement.
4. People have a right to be involved in decisions that
affect their working life, particularly their health and
well-being.
5. Co-operation between the two sides of industry,
essential to improve working conditions, should be
based on an equal partnership.”
In terms of international standards offered for adoption as
national laws, the ILO Occupational Safety and Health
Convention 1981 (C155), Article 20, states the basic
approach:
“Co-operation between management and workers
and/or their representatives within the undertaking
shall be an essential element of organisational and
other measures taken in pursuance of Articles 16 to 19
of this Convention.”
Copyright © International Labour Organisation 1981
This is supported directly by the associated R164
Occupational Safety and Health Recommendation
(see especially Article 12). Also relevant are the ILO
Co-operation at the Level of the Undertaking
Recommendation (R94) and the ILO Communications
within the Undertaking Recommendation (R129),
which recommend consultation within the workplace.
Copyright © International Labour Organisation 2011
There is general agreement that consultative and
participatory arrangements have a direct effect on safety
performance.
© RRC International
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Consultation with Employees
FORMAL CONSULTATION
You probably have formal consultation arrangements in
your own workplace. These may even be mandated by
local laws, e.g. implementing Article 19(a)-(e) of the ILO
Safety and Health Convention:
“There shall be arrangements at the level of the
undertaking under which-(a) workers, in the course of performing their work,
co-operate in the fulfilment by their employer of the
obligations placed upon him;
(b) representatives of workers in the undertaking cooperate with the employer in the field of occupational
safety and health;
(c) representatives of workers in an undertaking are
given adequate information on measures taken by the
employer to secure occupational safety and health
and may consult their representative organisations
about such information provided they do not disclose
commercial secrets;
(d) workers and their representatives in the
undertaking are given appropriate training in
occupational safety and health;
(e) workers or their representatives and, as the case
may be, their representative organisations in an
undertaking, in accordance with national law and
practice, are enabled to enquire into, and are consulted
by the employer on, all aspects of occupational safety
and health associated with their work; for this purpose
technical advisers may, by mutual agreement, be
brought in from outside the undertaking;”
• Access to all parts of the workplace, workers, labour
inspectors and health and safety specialists (as
required).
• Allowed reasonable time (paid) and given training to
perform their functions.
For some useful discussions on the role of safety
representatives and safety committees, see the ILO training
materials Introduction to Occupational Health and Safety,
available from the ILO at:
http://actrav.itcilo.org/actrav-english/telearn/osh/intro/
inmain.htm.
The main role of representatives is to work actively to
prevent worker exposure to occupational hazards. Typical
activities include:
• Workplace observations and inspections.
• Examination of records.
• Listening to complaints.
• Reading information.
• Asking members represented what they think.
To support the role, representatives need to keep
informed about their workplace hazards and possible
control measures, and work in partnership with the union
(if applicable, or otherwise the represented group) and the
employer for hazard identification and control.
Health and Safety Committees
Copyright © International Labour Organisation 1981
Worker Representatives
An approach to fulfilling the obligations under Article
20 of the Convention (see earlier) is suggested within
the associated Recommendation R164 (Article 12). This
involves the appointment of:
• Workers’ safety delegates (often called “safety
representatives”).
• Workers’ safety and health committees and/or joint
safety and health committees.
Representatives should have the following functions,
rights and entitlements:
• Be given adequate information on health and safety
matters.
Consultation with workers
Union Committees
There are several types of health and safety committee,
one being a local union committee. This has no employer
involvement. According to the ILO training guide, the role
of the local union committee is to:
• Consulted (when major health and safety measures or
changes to work with health and safety implications are
planned).
• Respond to worker concerns.
• Protection from dismissal/prejudicial treatment.
• Educate union members in health and safety.
• Be able to contribute to the health and safety decisionmaking process/negotiations.
• Help represent workers’ health and safety grievances to
management.
6-18
• Initiate action on the hazards it recognises.
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Consultation with Employees
In the absence of a joint worker-management safety
committee, the local union committee would have to deal
directly with management.
Membership should have representation from all work
areas and shifts (different unions should attempt to work
together as a single committee). Members should be
concerned about health and safety and want to learn more,
and meetings should be held monthly.
Typical activities of such committees would include:
• Holding regular meetings to discuss issues brought to
its attention by members, suggesting possible solutions
and progress reports on issues being tackled.
• Developing health and safety training programmes.
• Researching specific health and safety issues to aid
negotiations with management.
• Accompanying government inspectors on workplace
inspections.
Joint Labour-Management Committees
These involve management as well as workers. In terms
of membership, generally there should be at least two
worker representatives, selected with the agreement of the
unions (where applicable), or possibly from the local union
committee. Members should have an interest in health
and safety and a desire to co-operate. It is suggested that
equal numbers of workers and management should be
on the committee. The management members should, as
far as possible, have the authority to make the necessary
decisions and to allocate resources.
Typical activities of these committees would include:
• Promoting health and safety in the workplace
(including providing training).
• Monitoring the workplace for hazards and legal
compliance (including inspections).
• Agreeing the health and safety policy and its
implementation.
INFORMAL CONSULTATION
Informal consultation can be more effective than formal.
There are numerous opportunities for discussion during
workplace inspections, toolbox talks, induction training,
safety audits and staff appraisals. Individuals may often
express genuine personal feelings in a one-to-one
situation, in a more open manner when free from peer
group pressure.
Discussion Groups and Safety Circles
• Discussion groups consist of a group of individuals
coming together to discuss issues of mutual interest.
In the workplace, groups may be formed, often from
volunteers, to deal with a number of issues both work
and non-work related. They may be given certain
remits, such as safety and quality.
• Safety circles are small groups of workers - not safety
representatives or members of safety committees who meet informally to discuss safety problems in
their immediate working environment. The idea is
based on the ‘quality circles’ concept and allows the
sharing of ideas and the suggestion of solutions. Any
insurmountable problem would be referred to the
safety representative or safety committee.
Departmental Meetings
These meetings are normally attended by shop-floor
representatives, supervisory and management staff who
will meet frequently, often once a week, to discuss general
matters affecting their department. Matters for discussion
might include: shift patterns, maintenance and breakdown
procedures, and production targets. It is difficult to
discuss any of these without impinging on health and
safety requirements and, although perhaps not a major
objective of such meetings, health and safety policies and
arrangements would come under examination. Again,
any health and safety problems identified would probably
be referred to senior management through the safety
representative or safety committee.
• Working with management to resolve health and safety
problems/complaints.
• Involvement in planning proposed changes that may
impact on health and safety.
• Keeping union members informed about planned
actions.
Informal consultation can take the form of departmental meetings
© RRC International
Unit IA – Element IA6: Organisational Factors
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Consultation with Employees
ROLE OF THE HEALTH AND SAFETY
PRACTITIONER IN THE CONSULTATIVE
PROCESS
The term ‘safety professional’ covers such diverse staff as:
safety advisers, occupational hygienists, doctors, nurses,
safety managers, human resources managers, training
officers, facilities managers, ergonomists, engineers and
radiation protection advisers. The qualifications range
from the highly qualified doctor to the human resources
manager who has completed perhaps a non-examination,
three-day, basic health and safety awareness course. The
health and safety practitioner needs to be a person with a
wide range of abilities and a recognised safety qualification
at diploma or degree level with IOSH membership. In
relation to the health and safety consultative process,
health and safety practitioners have a substantial role to
play. They are often the first contact for the employer
or worker on health and safety matters. The safety
practitioner maintains a number of relationships:
• Within the Organisation
–– The position of health and safety practitioners
in the organisation is such that they support the
provision of authoritative and independent advice.
–– The post-holder has a direct reporting line to
directors on matters of policy and authority to stop
work which is being carried out in contravention of
agreed standards and which puts people at risk of
injury.
–– Health and safety practitioners have responsibility
for professional standards and systems and, on a
large site, or in a group of companies, may also have
line management responsibility for junior health
and safety professionals.
• Outside the Organisation
Health and safety practitioners liaise with a wide range
of outside bodies and individuals including: local
government enforcement agencies; architects and
consultants, etc.; the fire department; contractors;
insurance companies; clients and customers; the public;
equipment suppliers; the media; the police; medical
practitioners; and hospital staff.
This is a very wide brief and indicates that the safety
practitioner requires a broad and extensive knowledge of
health and safety matters in order to fulfil his duties. He
is the organisation’s first contact when health and safety
problems are encountered, and will give advice on shortterm safety solutions to problems and follow this through
with perhaps a recommendation for a change in policy or
the introduction of new technology or new/revised safe
systems of work. He will also recommend the services of
outside expert consultants where the problem requires
scientific, medical or technical advice which is outside
his area of expertise. He may also be involved in safety
committees in a chairing role or simply in an advisory
capacity during committee deliberations.
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BEHAVIOURAL ASPECTS ASSOCIATED WITH
CONSULTATION
In any social group, conflict may arise between two or
more people, interest groups, genders, ethnic or racial
groups, etc. Obviously where there are assemblies of
people in the workplace, there may be conflict within
and between groups. Safety committee member A
serves on the committee to represent his department or
perhaps a particular group of workers with common skills.
Similarly, committee member B represents his department
members. A and B, although sharing a common
membership of the safety committee, may well be pursuing
different objectives. They may both be seeking improved
health and safety arrangements for their members but may
be in competition for the allocation of limited resources to
their particular project.
Peer Group Pressures
The safety representative serving on a safety committee
may see his role as one in which he feels the need
to question and destructively criticise, as a matter of
course, any suggestion advanced from a management
representative on the committee. Remember, however,
that the safety representative is a worker’s representative
and not part of the management team - neither is he
necessarily “a competent person”. His perception of
health and safety problems will be different from that
of management and not constrained by budgeting
considerations. His role is primarily a policing one in which
he monitors the safety performance of management and,
because of peer group pressure, he may see himself in a
conflicting, rather than co-operative, role.
Dangers of Tokenism
Tokenism is an approach where management goes through
the motion of consultation but has no real intention of
taking on board the views expressed by employees. There
is no strict obligation on the employer to implement
suggestions from employees arising from the consultation
process (unless there is a specific legal requirement), but
the employer should respond positively to information
gained during the consultation process. If proposals are
seen to be rejected without justification, this is likely to
generate general resentment and apathy towards the
process, and have a detrimental effect on the health and
safety culture.
Potential Areas of Conflict
The safety representative can sometimes see himself as an
expert on health and safety matters, while management
may take the view that their opinions are correct,
simply because they are management and know better.
Consultation about problems where the views of all the
participants are considered should lead to a lessening of
conflict, and arrival at effective decisions.
| Unit IA – Element IA6: Organisational Factors
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v2.1
Consultation with Employees
DEVELOPMENT OF POSITIVE CONSULTATIVE
PROCESSES
GLOSSARY
Contributions of Employee
Representatives/Safety Committee
Members
We discussed the functions of safety representatives and
committee members earlier. Employee representatives for
health and safety:
CONSULTATION
• To seek advice or information.
• Will have a basic health and safety knowledge
(legislation, guarding, noise, etc.).
• To consider in company.
• To take counsel.
• Need to be active in promoting and encouraging a
health and safety culture amongst their colleagues:
• To give or receive professional advice.
• To confer with two or more in counsel.
We all have one or more of those definitions in mind
whenever we see the word “consultation”, but what about
“positive consultation”? Some managements believe
that informing the workforce after they have decided to
introduce some new technology or downsize the company
by means of a redundancy programme is “consultation”.
This it is certainly not. Consultation means to discuss (with
others) a given agenda and to give or receive information
or advice about that agenda before taking any action
or arriving at decisions about possible courses of action.
Positive consultation is based on a willingness on both sides
- employer and worker - to consider problems together, to
make use of each other’s knowledge and expertise, and to
apply that collective wisdom to the problem in hand.
The emphasis in positive consultation must be on prior
consultation followed by effective decision-making based
on the collective expertise and knowledge drawn from
both sides. Consultation is particularly necessary on such
matters as:
• The introduction of any new measure at a workplace
that may substantially affect health and safety.
• Arrangements for appointing competent persons
to assist the employer with health and safety, and
for implementing procedures relating to serious and
imminent danger.
• Any health and safety information that the employer is
required to provide.
• The planning and organisation of health and safety
training, and health and safety implications of the
introduction, or planned introduction, of any new
technology.
We have said that consultation, to be positive, has to be
a “joint” and “prior to the event” enterprise. The above
four points outline management’s role in the consultative
process but the representatives themselves must be
active in promoting and encouraging a health and safety
culture among their colleagues. To do this they must
keep themselves informed of developments in health and
safety, encourage co-operation between workers and the
employer in the promotion of any measures designed to
improve health and safety in the workplace, and above all
lead by example.
© RRC International
–– Keeping themselves informed of developments in
health and safety.
–– Encouraging co-operation between workers and
the employer in the promotion of any measures
designed to improve health and safety in the
workplace.
–– Leading by example.
Safety committee members:
• Will have some health and safety knowledge (but
probably less than the representative).
• Are likely to have a more reactive role than that of the
representative (discussing reactive data such as accident
reports/investigations).
The safety committee has an important role in following
up problems which have not been satisfactorily resolved
by safety representative intervention. The normal chain of
events would be:
• Worker complains to line management - problem
remains unresolved.
• Safety representative complains to line management
on worker’s behalf - problem remains unresolved.
• Matter is referred to the safety committee:
–– Matter resolved - no further action.
–– Matter unresolved - referred to senior management
by resolution of committee.
Urgent health and safety matters must not be delayed
until the next meeting of the safety committee but
referred immediately to senior management by the safety
representative. It is clear from these arrangements that
the safety representative and safety committee member
have complementary roles which, if followed correctly,
contribute effectively to the good health and safety
management of any organisation.
Unit IA – Element IA6: Organisational Factors
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Consultation with Employees
REVISION QUESTIONS
6. Outline the main role of worker representatives
on health and safety and their typical activities.
7. Outline the typical activities of a labourmanagement safety committee.
8. What is a safety circle?
9. What do you understand by the term “positive
consultation”?
(Suggested Answers are at the end.)
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Health and Safety Management Information System
KEY INFORMATION
• It is common in many regions of the world to find legal duties (either explicit or implied) to provide information
to:
–– Suppliers.
–– Workers.
–– Enforcement authorities.
–– Temporary workers.
–– Employment agencies.
–– Contractors.
–– Members of the public.
–– Customers.
• The basis of sound health and safety information management comprises the collection of information, its
documentation and the provision of systems for cascading information to users.
• A broad range of both internal and external information is needed for an effective health and safety management
information system. This includes:
––
––
––
––
Loss event data.
Cost data.
Suppliers’ data.
Results of audits and inspections.
HEALTH AND SAFETY MANAGEMENT
INFORMATION SYSTEMS WITHIN THE
WORKPLACE
The following figure illustrates how external and internal
health and safety materials are combined, processed and
turned into user-friendly information for use by company
workers and contractors, visitors, customers, etc.
The basis of sound health and safety information
management comprises:
• The collection of information from external sources.
• The documentation of policy, organisation statements,
performance standards, rules and procedures (including
risk assessments, audits, inspections, test results, and
accident statistics, etc.).
• Provision of systems for cascading information.
• Use of posters, bulletins, newspapers, etc.
The starting point in the development of the system is to
appoint someone with the professional competence to
manage it. In many organisations this might be an existing
manager or a dedicated safety professional. Whoever
he/she is, the safety manager must keep up to date
with developments in legislation and current practice
through membership of a professional association(s) and
arrange for the collection and systematic documentation
of relevant developments in health and safety. He/she
should subscribe to a number of professional publications
and attend courses and seminars to maintain “continuing
professional development” status. He/she will also be
responsible for the collection and documentation of
internal health and safety information, the safety policy,
risk assessments, test results, accident reports and statistics,
and health surveillance. The safety practitioner must be
able to interpret legislation, manufacturers’ instructions,
and a variety of other technical or semi-legal documents.
The information collected, both externally and internally,
must then be used as a management tool for the efficient
running of the organisation.
© RRC International
Unit IA – Element IA6: Organisational Factors
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Health and Safety Management Information System
ORGANISATION
Internal Information
Sources
External
Information Sources
H & S Information Process/
Retrieval System
External End-User
Internal End-User
Internal and external health and safety materials
TYPES OF DATA WITHIN A HEALTH AND
SAFETY MANAGEMENT INFORMATION
SYSTEM
TOPIC FOCUS
EXTERNAL INFORMATION SOURCES
INTERNAL INFORMATION SOURCES
Legislation, codes of practice and guidance.
H and S policy document.
National and international Standards.
Compliance data.
Manufacturers’ instructions.
Cost data.
Risk assessments.
Guidance from safety and professional bodies,
e.g. ILO, WHO, IOSH.
Guidance from industrial bodies.
Monitoring results:
• Noise.
• Dust.
• Lighting.
• Atmospheric, etc.
Job descriptions.
Job safety analyses.
Results of inspections/audits.
Accident and ill-health reports/statistics.
Training records.
Management system performance data.
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Health and Safety Management Information System
Such health and safety information can be assimilated
into the organisation and held centrally. The appropriate
material can then be redistributed throughout the
organisation, or to those departments which have a
specific requirement. Information can be filed manually or
stored electronically for ease of retrieval and copying.
REQUIREMENTS AND PRACTICAL
ARRANGEMENTS FOR PROVIDING HEALTH
AND SAFETY INFORMATION
We have already discussed some of this under “Third
parties” earlier. It is common in many regions of the world
to find legal duties (either explicit or implied) to provide
information to, for example:
• ILO Safety and Health in Construction Convention
C167
Article 33 – provision of information to workers on
health and safety hazards.
• ILO Prevention of Major Industrial Accidents
Convention C174
Article 9 – provision of information to authorities on
potential accidents, etc.
Article 16 - information to the local public from
competent authority on action to take in case of major
accident.
• Workers.
• Temporary workers.
• Contractors.
• Customers.
•
Suppliers.
• Enforcement authorities.
• Employment agencies.
• Members of the public.
In terms of global guidelines, the following ILO
conventions and recommendations will help illustrate
the point of explicit mention of information provision
(though it is implied in many other areas too, such as “cooperation” and “consultation” touched on earlier):
• ILO Occupational Health and Safety Convention
C155
Article 19(c) – employers to provide health and safety
information to worker representatives.
• ILO Protocol of 2002 to the Occupational Health
and Safety Convention P155
Articles 3(a)(ii) and 4(a)(ii) – provision of information
to workers regarding accident reporting systems and
notified accidents.
• ILO Occupational Health and Safety
Recommendation R164
Article 12(2) – provision of health and safety
information to safety representatives/committees, etc.
Article 14 – information on health and safety policy/
organisation/arrangements brought to attention of
workers.
• ILO Communications Within the Undertaking
Recommendation R129
Article 2(2) – dissemination of information.
REVISION QUESTIONS
10. Identify categories of people to whom
information would normally be provided by your
organisation.
11. List the external sources of health and safety
information.
12. List the internal sources of health and safety
information.
(Suggested Answers are at the end.)
© RRC International
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Health and Safety Culture and Climate
KEY INFORMATION
• Safety culture may be defined as “a system of shared values and beliefs about the importance of health and safety
in the workplace”.
• The safety climate is an assessment of people’s attitudes and perceptions at a given time.
• Organisational factors, e.g. training, availability of suitable equipment, behaviour of managers, etc. influence
individual behaviour.
• There are many indicators of the health and safety culture of an organisation, e.g. housekeeping, relationships
between managers and workers.
• Safety culture and climate may be assessed by:
–– Perception surveys.
–– Findings of incident investigations.
–– Effectiveness of communication.
CULTURE AND CLIMATE
GLOSSARY
HEALTH AND SAFETY CULTURE
“A system of shared values and beliefs about
the importance of health and safety in the
workplace”
Unfortunately there is no universal definition and many
authors use the terms culture and climate interchangeably.
One commonly accepted explanation is given by Cooper
(2000) who distinguishes between three related aspects of
culture:
• Psychological aspects – how people feel, their attitudes
and perceptions – safety climate.
• Behavioural aspects – what people do.
or
“An attitude to safety which pervades the
whole organisation from top to bottom and has
become a norm of behaviour for every member
of staff from the board of directors down to the
newest juniors”.
Yet another definition by the UK’s Advisory
Committee on the Safety of Nuclear Installations is:
“The safety culture of an organisation is the
product of individual and group values, attitudes,
perceptions, competencies, and patterns of
behaviour that determine the commitment to,
and the style and proficiency of, an organisation’s
health and safety management. Organisations
with a positive safety culture are characterised
by communications founded on mutual trust, by
shared perceptions of the importance of safety
and by confidence in the efficacy of preventive
measures.”
6-26
What, then, is safety climate?
• Situational aspects – what the organisation has –
policies, procedures, etc.
It is generally accepted that safety climate refers to the
psychological aspects of health and safety and is measured
through a safety climate or attitude survey (see later).
The important thing to remember about a safety culture
is that it can be positive or negative. A company with a
negative or poor safety culture will struggle to improve
safety or prevent accidents, even if they have excellent
written procedures and policies, and state-of-the-art
safety equipment. The reason for this really comes down
to people, their attitudes to safety and how this attitude is
encouraged and developed.
| Unit IA – Element IA6: Organisational Factors
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Health and Safety Culture and Climate
IMPACT OF ORGANISATIONAL CULTURAL
FACTORS ON INDIVIDUAL BEHAVIOUR
• Management visibility – senior managers show
commitment and are visible ‘on the shop floor’.
We are all influenced to some degree by things that we see
and hear. Large amounts of money are spent on television
advertising because companies know how influential
television can be - our behaviour is being moulded by an
influential medium. In the workplace, who and what are
likely to influence our behaviour when it comes to safety?
• Balance of productivity and safety – the need for
production is properly balanced against health and
safety so that the latter is not ignored.
Typical answers might include:
• Job satisfaction – confidence, trust and recognition of
good safety performance.
• Managers and Supervisors
If they appear to condone poor behaviour, then it is
likely to go unchecked. Does safe behaviour rank way
below productivity? Do they show commitment to
safety and lead by example? Do they commit sufficient
resources to health and safety?
• High quality training – training is properly managed,
the content is well chosen and the quality is high.
Counting the hours spent on training is not enough.
• Workforce composition – a significant proportion of
older, more experienced and socially stable workers.
This group tend to have fewer accidents, and lower
absenteeism and turnover.
• Work Colleagues
The way that colleagues behave will probably have
an influence on others. What is their attitude to risk
taking?
• Training
Not being trained in correct procedures and use of
equipment can affect health and safety. Does the
organisation see training as a priority? Is the training
appropriate?
• Job Design
Job design may be done in a way that makes safe
behaviour difficult. How much consideration has been
given to the layout of the job and the needs of the
individual?
• Work Equipment
If this is not kept in good order, or is unavailable, it
may affect health and safety. What is the organisation’s
attitude to equipment maintenance?
The UK’s HSE publication, Reducing Error and Influencing
Behaviour (HSG48), identifies certain factors associated
with good safety performance:
• Effective communication – between, and within,
levels of the organisation, and comprehensive formal
and informal communication.
All staff are focused on health and safety
• Learning organisation – the organisation continually
improves its own methods and learns from mistakes.
• Health and safety focus – a strong focus by everyone
in the organisation on health and safety.
• Committed resources – time, money and staff
devoted to health and safety showing strong evidence
of commitment.
• Participation – staff at different levels in the
organisation identify hazards, suggest control measures,
provide feedback and feel that they ‘own’ safety
procedures.
© RRC International
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Health and Safety Culture and Climate
INDICATORS OF CULTURE
TOPIC FOCUS
Indicators of safety culture within an
organisation include:
• Housekeeping.
• The presence of health and safety warning
notices throughout the premises.
• The wearing of PPE.
• Quality of risk assessments.
• Good or bad staff relationships.
• Accident/ill-health statistics.
• Statements made by employees, e.g. “My
manager does not care” (negative culture).
Some of these indicators will be easily noticed by a
visitor and help to create an initial impression of the
company.
CORRELATION BETWEEN HEALTH AND
SAFETY CULTURE/CLIMATE AND HEALTH
AND SAFETY PERFORMANCE
It is quite easy to identify a correlation between cultural
indicators and health and safety performance. An
experienced safety practitioner can often gauge the
standard of safety performance of an organisation from an
initial walk-round and first impressions. The standard will
often be confirmed on completion of a detailed audit/
inspection.
Subjective and Objective Nature of
Culture and Climate
The culture of an organisation refers to objective
characteristics that can be observed or inferred by an
outside observer. For example, the structure of the
organisation and the roles and rules can be observed. The
deep-seated values of the organisation, e.g. a respect for
tradition or service to customers, can be inferred by an
outsider.
MEASUREMENT OF THE CULTURE AND
CLIMATE
While there are many indicators which can give a first
impression of a company’s safety culture/climate, it is
possible to measure some of the indicators to obtain a
more accurate picture of the sense of culture within an
organisation.
There are a number of measurement tools available.
Safety Climate Assessment Tools
The Health and Safety Laboratory (HSL) has published a
safety climate tool which uses eight key factors mapped
around 40 statements on which respondents are asked to
express their attitude.
• Organisational commitment.
• Health and safety behaviours.
• Health and safety trust.
• Usability of procedures.
• Engagement in health and safety.
• Peer group attitude.
• Resources for health and safety.
• Accidents and near-miss reporting.
The kit is available in a software format and will analyse
and present the results as charts that can be easily
communicated to the workforce.
MORE…
You can find further details of the HSL Safety
Climate Assessment Tool at:
www.hsl.gov.uk/products/safety-climate-tool.aspx
In the UK, Loughborough University have developed
a Safety Climate Assessment Tool which may be
downloaded from:
www.lboro.ac.uk/media/wwwlboroacuk/
content/sbe/downloads/Offshore%20Safety%20
Climate%20Assessment.pdf
The climate of an organisation, however, is more
subjective. This is because it is the way people within
the organisation perceive its structures, roles, rules and
authority, etc. For example, do individuals feel like a valued
member of the organisation or do they just feel like a
number? The insider’s view is more difficult to obtain and
is usually only discovered by in-depth research.
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Health and Safety Culture and Climate
Perception or Attitude Surveys
These are survey questionnaires (often within a safety
climate tool) containing statements which require
responses indicating agreement or disagreement.
Respondents are asked to indicate to what extent they
agree or disagree with each statement, generally using
a five-point scale which can then be coded to give a
score. High scores represent agreement and low scores
disagreement.
It is not difficult to produce a questionnaire about general
health and safety which would give some idea as to the
safety culture within an organisation. The questionnaire
must be worded to avoid bias, and to obtain truthful
answers, confidentiality is necessary. When carried out
properly these surveys can identify underlying anxieties
and problems which would be difficult to identify by
any other means. Take care, however, to make sure that
the questionnaires themselves do not create anxiety or
suspicion in the minds of workers. When carried out
regularly, attitude surveys can identify trends and it is then
possible to quantify how attitudes are changing.
The process of communication requires a sender, a receiver
and feedback. Feedback is the part that is often left out of
the process and this is what leads to problems. Successful
communication is measured by feedback which allows the
sender to test whether the receiver has fully understood
the communicated message.
Communication methods are written, verbal or visual,
or a combination of all three. The method chosen
must be appropriate to the type of information to be
communicated and its objectives, the sophistication of the
audience (receivers), and the structure and culture of the
organisation.
Communication surveys can be used to find out how
effectively information has been transferred to new
members of staff. A sample of comparatively new
members of staff can be interviewed to identify how well
they have assimilated the company’s safety culture, or
how much they have retained from company health and
safety training. This type of survey can be done formally or
informally.
Effective communication involves:
Findings of Incident Investigations
• Including everyone who should be included.
Sometimes during an accident/incident investigation the
underlying cause is identified as ‘lack of care’. This may
indicate individual carelessness or, where carelessness is
found to be the widespread cause of accidents/incidents,
then this may be an indicator of poor safety culture.
• Not overloading people with large quantities of
information; prioritise anything urgent.
Where the same underlying cause keeps recurring, the
safety manager has to introduce a process of education
or re-education of the workforce to encourage a change
of attitude. The findings and lessons learned from
incident investigation are invaluable in preventing similar
occurrences, setting policy, formulating safe systems of
work, writing training materials and, after publication to
the workforce, demonstrating company commitment to
the principles of good safety management.
• Being selective; sending only what is necessary.
Effectiveness of Communication
• Being brief, direct and keeping it simple.
• Being fast but not at the expense of accuracy.
• Encouraging feedback to ensure the message has been
received and understood.
• Using as few links in the communication chain as
possible to prevent distortion of the original message.
Evidence of Commitment by Personnel at
All Levels
GLOSSARY
GLOSSARY
COMMITMENT
COMMUNICATION
Can be defined as: “a declared attachment to a
doctrine or cause”.
“Communication is the transfer of information
from one person to another with the information
being understood by both the sender and receiver.”
(Koontz)
© RRC International
It is the goal of the safety practitioner to ensure
commitment to health and safety by everyone within
an organisation. This commitment must start at the
management board level. It is essential that management
show their commitment to safety as this sets the standard
for the whole organisation. The workforce will only believe
in this commitment if they know that management are
willing to sacrifice productivity or time in order to ensure
worker safety.
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Health and Safety Culture and Climate
Evidence of commitment can be seen by management
visibility. If managers are not seen on the “shop-floor” or at
the “sharp end of activity”, workers may assume that they
are not interested in the job or health and safety. Lack of
management visibility is seen as a lack of commitment to
safety and this becomes part of the organisation’s safety
culture.
Visible commitment can be demonstrated by
management:
• Being seen and involved with the work and correcting
deficiencies.
• Providing resources to carry out jobs safely (enough
people, time and money, providing appropriate
personal protective equipment, etc.).
• Ensuring that all personnel are competent (providing
training and supervision).
• Enforcing the company safety rules and complying with
them personally (introducing safe systems of work and
insisting on their observance).
• Matching their actions to their words (correcting
defects as soon as is reasonably practicable, avoidance
of double standards).
REVISION QUESTIONS
13. Define the term “safety culture”.
14. How may the safety climate of an organisation
be assessed?
15. Name three ways in which management
commitment can be demonstrated.
(Suggested Answers are at the end.)
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Factors Affecting Health and Safety Culture and Climate
KEY INFORMATION
• A positive health and safety culture or climate is promoted by:
–– Management commitment and leadership.
–– High business profile to health and safety.
–– Provision of information.
–– Involvement and consultation.
–– Training.
–– Promotion of ownership.
–– Setting and meeting targets.
• A negative health and safety culture or climate may be promoted by:
–– Organisational change.
–– Lack of confidence in organisational objectives and methods.
–– Uncertainty.
–– Inconsistent signals from management.
• To effect a cultural or climate change needs:
–– Good planning and communication.
–– Strong leadership.
–– A step-by step approach.
–– Action to promote change.
–– Strong worker engagement.
–– Ownership at all levels.
–– Training and performance measurements.
–– Feedback.
• Problems with culture or climate change may arise from:
––
––
––
––
Attempting to change it too quickly.
Changing everything at the same time.
Lack of trust in communications.
Resistance from those not committed to change.
High Business Profile to Health and Safety
PROMOTING A POSITIVE HEALTH AND
SAFETY CULTURE
Management Commitment and
Leadership
The most important thing is ‘leading by example’. As soon
as management undermines the safety standards in order
to increase productivity, or ignores an unsafe act, then they
lose worker respect and trust, and the whole safety culture
of the organisation is threatened. It is important to ensure
that management behaviour is positive in order to produce
positive results and a positive culture.
A positive health and safety culture can be promoted by
including safety in all business documents and meetings. All
newsletters, minutes of meetings, notices, advertisements
and brochures can include an appropriate reference to
safety; it could simply be reference to the organisation’s
commitment to safety (e.g. a safety phrase appearing on
all notepaper) or, with respect to meetings, it could be an
opportunity for any safety concerns to be raised. If safety is
seen as an integral part of the business then the profile of
safety will be raised.
Provision of Information
It is really important to provide information about health
and safety matters in the form of posters, leaflets, or in
staff newsletters.
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Factors Affecting Health and Safety Culture
Involvement and Consultation
Setting and Meeting Targets
It is vital to involve staff members in health and safety
matters. Areas in which staff representatives or health and
safety representatives can be actively involved include:
Setting safety targets for individuals or teams can have a
positive effect on a safety culture. Usually there will be an
incentive, perhaps a bonus, linked to performance-related
pay or an award or prize. The target could be, for example,
to obtain a higher score in a health and safety inspection.
• Risk assessments.
• Workplace inspections.
• Accident investigations.
• Safety committee meetings.
It is also a legal requirement to consult with employees in
good time regarding:
• The introduction of any measures which may
substantially affect their health and safety.
• The arrangements for appointing or nominating
competent persons.
• Any health and safety information to be provided to
employees.
• The planning and organisation of any health and safety
training.
• Health and safety consequences of introducing new
technology.
We discussed the subject of consultation with workers in
depth earlier in this element. Involving and consulting with
workers is an important process for getting them to take
ownership of health and safety issues. The fact that they
or their colleagues have been involved in health and safety
matters encourages respect for safety rules and improves
attitudes towards safety. These values all help to produce a
more positive safety culture within the organisation.
Aiming for the target should encourage people to work
together in order to achieve it and this usually means
people talking about health and safety and ways to
improve it.
Once the target is met, that standard must be maintained
and further improvements encouraged by setting another
target. The targets must, however, be achievable in order to
prevent workers becoming disheartened and abandoning
the target.
FACTORS THAT MAY PROMOTE A NEGATIVE
HEALTH AND SAFETY CULTURE OR CLIMATE
There are a number of factors that may contribute to a
negative health and safety culture.
Organisational Change
Company reorganisations often leave individuals worried
about job security and their position in the organisation.
Many people fear change and, unless it is handled correctly,
will mistrust management and become suspicious of any
alterations to their role or environment (even ones that are
beneficial).
Reasons for company reorganisation may be:
• A merger.
• Relocation of the business.
Training
• Redundancies.
Training is vital to ensure that people have the right skills
to carry out their job safely. Training also makes individuals
feel valued and is an important part of their personal
growth and achievement. Workers who receive training are
more likely to be motivated and take newly-learned skills
or ideas back to the workplace.
• Downsizing.
Promotion of Ownership
There are many ways to promote ownership in individuals.
We have mentioned involvement and consultation already,
but simply talking to people and asking their opinion
or their thoughts on a health and safety problem can
encourage them to think about health and safety and what
they can do to improve it.
• External pressures over which the organisation has no
power.
Companies may offer voluntary redundancies to make
the job losses more acceptable, but sometimes the
redundancies are compulsory. The company may offer
generous financial packages to soften the blow to workers,
and in some countries there may be statutory redundancy
payments. Problems may occur, however, when the
retained workers have to work with reduced manpower
and resources - they may feel threatened by the possibility
of further redundancies, leading to bitterness and anger.
Further resentment may develop where shareholders and
directors are seen to benefit from the loss of colleagues
who have been forced to leave the business.
Where outside pressures are the cause of the
reorganisation workers may be more understanding than
if the changes are brought about by the need to improve
profits.
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Factors Affecting Health and Safety Culture
Frequent reorganisations can be damaging to a company
unless they are handled well. Increased workforce
dissatisfaction may lead to some workers leaving, which
in turn can leave gaps in the operation which cause
further difficulties. This type of situation can lead to more
accidents and incidents, as well as increased sickness and
absence from work.
Lack of Confidence in Organisation’s
Objectives and Methods
Most companies have objectives relating to productivity
and safety. If productivity appears to take precedence
over safety, however, then worker perception will be that
the company is unethical and untrustworthy with little
commitment to safety, which will lead to a subsequent
deterioration in the safety culture.
Examples where workers may feel that safety has been
compromised in order to achieve productivity include:
Management Decisions that Prejudice
Mutual Trust or Lead to ‘Mixed Signals’
Regarding Commitment
Management decisions which are, or are perceived to
be, inconsistent or poorly made can generate unrest and
distrust in an organisation. There may be good reasons for
the decision which is why it is extremely important that
management are aware that good communication is an
important part of the decision-making process.
Circumstances that could give rise to distrust and doubt
about management commitment generally (these could
equally apply to decisions about safety) include:
• Where there are no rules or no precedents, decisions
may appear to be arbitrary and inconsistent.
• Workers expected to wear PPE, whereas visitors or
managers are not.
• Safety improvements only made after incidents have
occurred.
• Refusal to delegate decision-making leads to
demotivation and diminution of a sense of
responsibility in subordinates.
• Double standards in the application of safety
regulations by safety advisers and management.
• Constant rescinding by senior management of
decisions made at lower levels of management.
• Unsafe practices ignored in order to improve
productivity.
• Delays in making decisions.
• Permit-to-work systems not being operated as they
should be.
• Decisions affected by conflicting goals between
management and worker.
• Decisions affected by conflicting goals between
different departments.
• Changes made to safety rules during operation.
• Lack of consultation prior to decision-making.
EFFECTING CULTURAL OR CLIMATE CHANGE
There are three factors that should be considered when
managing a change in culture:
• Dissatisfaction with the existing situation, e.g. too many
near misses.
• A vision of the new safety culture.
• Understanding how to achieve it.
Unsafe practices may be ignored to improve productivity
Uncertainty
Security is a basic human need. In an uncertain
environment, people generate feelings of insecurity. When
security cannot be assured, humans cannot achieve their
full potential. Uncertainty about the future can lead to
dissatisfaction, lack of interest in the job and generally poor
attitudes towards the company and colleagues.
Uncertainty is often caused by management behaviour
which sends mixed behaviour signals to the workforce.
If management are seen to say one thing and then do
something different, this undermines their authority and
credibility, e.g. managers drinking on the job or failing to
wear PPE.
© RRC International
Change is an inherent part of modern life, but there are
many people who find change difficult to deal with and
who are afraid of it. In order to effect change within an
organisational culture, you have to plan the strategy and
communicate from the beginning in order to involve
workers and not alienate them.
Planning and Communication
Planning for change should start at the top of the
organisation, but should encourage participation at all
levels. There should be clear objectives as to what is to
be achieved by the proposed change, e.g. a cost-benefit
analysis of the changes suggested.
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Factors Affecting Health and Safety Culture
Plans for change should clearly designate who is
responsible for initiating and implementing specified
changes, as well as how each stage of the change process
will be conducted. Effective communication between all
those implementing change is crucial.
To prevent rumours circulating and misunderstandings
developing, it is important to publicise information relating
to the pending change as early as possible. Wherever
possible, direct briefings, meetings or interviews should
keep managers and staff aware of proposed changes and
the progress made as changes get underway.
Strong Leadership
Managers at all levels need to demonstrate strong
leadership and not give inconsistent or mixed messages.
A Gradualist (Step-by-Step) Approach
One of the ways of effecting change in an organisational
culture is by taking a gradualist (step-by-step) approach,
with changes phased in over a period of time. The main
advantage of this approach is that it ensures that there is
time for adaptation and modification; it also allows time
for the change to become part of the established culture.
The major disadvantage of this approach is that the
changes take a relatively long time to implement. This can
mean that unsatisfactory conditions and mindsets may be
left in place for longer than is desirable.
Action to Promote Change
• Direct
This is where positive action is carried out with the sole
objective of effecting change, perhaps by setting up a
two-tiered system, i.e. a steering group and a working
party. The steering group should consist of high level
personnel (e.g. directors and heads of departments)
who give broad objectives, set timescales and meet
approximately every three months. The working party,
however, will meet every month and will consist of
middle management, first-line supervisors and union/
worker representatives. The working party will carry
the ‘message’ to the workforce and provide feedback.
• Indirect
Indirect methods bring about change, but they are
not necessarily the primary reason for carrying out
the method. For example, risk assessments identify
deficiencies in the workplace and corrective action
to put them right. Widespread use can indirectly
encourage a risk assessment mindset or attitude (a
culture of greater awareness of risks, etc.).
Strong Worker Engagement
Cultural change is not the sole responsibility of
management; there also has to be significant commitment
from workers who must recognise the need for change.
Ownership at All Levels
All individuals at all levels must be engaged in the process
and be committed to change.
Training and Performance Measurements
• Training courses can include information about new
or impending safety legislation or safety technology
thereby indirectly paving the way for future changes.
• Performance measurements can be introduced
to encourage workers to have a greater interest and
involvement in health and safety. Where performance
measurements improve over time, they can be linked
to an incentive scheme, but they should not be
linked to accident/incident rates as this can lead to
under-reporting. Performance measurements are an
inexpensive way of promoting health and safety, but
they need the support of management and unions to
be successful.
Importance of Feedback
Feedback is crucial to ensure that any changes
implemented are working successfully. Feedback from
workers will enable management to evaluate the new
processes, and fine-tune them where necessary.
The chair of the working party should also be a
member of the steering party and this role is usually
filled by a safety professional who can act as the link
between the two groups.
The pace of change should be dictated by the feedback
given by the working party.
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Factors Affecting Health and Safety Culture
PROBLEMS AND PITFALLS RELATING TO
CHANGE
In many cases the introduction of change within an
organisation is accompanied by problems such as conflict.
Problems associated with change include:
• Changing Culture Too Rapidly
Where changes have occurred too quickly workers
may feel extremely vulnerable, insecure, confused and
angry.
Where the changes have brought together new
personalities, then conflict between individuals may
occur. Differences of temperament are at their most
obvious when people are new to each other; a measure
of tolerance may build up over time.
• Adopting Too Broad an Approach
Trying to do too much all in one go can dilute the
resources so that little impact is seen. It is better to
target resources on fewer, manageable issues. It is
important to be clear about what the objectives are at
the start so that everyone is aware of the changes that
will occur.
• Absence of Trust in Communications
This is unsettling and demotivating. Inconsistent
management behaviour can lead to mistrust and
uncertainty causing a complete breakdown in
relations between management and the workforce.
Poor communications in periods of change can lead
to misunderstanding and confusion, which can fuel
conflict.
• Resistance to Change
Some people are more resistant to change than others.
Older people tend to be more resistant than young
people, and people with heavy financial commitments
tend to fear change as they need to feel secure.
Some people develop set patterns of thought and
behaviour which can be difficult to overcome when
change occurs. This is known as perceptual set, and
is the way in which observed information is processed
by the individual to fit his/her internal experience,
attitude, expectations, sensitivity and culture.
All these factors need to be considered and dealt with as
part of the change process.
REVISION QUESTIONS
16. Identify the features of a positive health and
safety culture within an organisation.
17. Briefly explain what is needed to effect cultural
change within an organisation.
(Suggested Answers are at the end.)
© RRC International
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Summary
SUMMARY
Internal and External Influences
Internal influences on the organisation include:
• Finance.
• Production targets.
• Trade unions.
• Organisational goals and culture.
External influences include:
• Legislation.
• Trade unions.
• Enforcement agencies.
• Insurance companies.
• Courts/tribunals.
• Public opinion.
• Contracts/contractors/clients.
Types of Organisations
An organisation is a group of persons who interact in order to achieve certain predetermined goals or objectives.
In a formal organisation, the organisation’s structure is based on relationships from the chief executive down. This
hierarchical structure is represented by the company organisation chart, or organogram.
The informal organisation is represented by individual and group behaviour, and depends on the quality of personal
relationships.
The organisation can be viewed as a system; different parts of an organisational system are functionally interrelated change in one part affects other parts of the organisation.
Conflict may arise as a result of individual goals not being consistent with those of the organisation.
Third Party Control
Definitions in this area:
• Third parties:
–– Contractors.
–– Visitors and trespassers.
–– Members of the public.
• The particular difference between contractors and other parties.
There are legal, moral and economic reasons for ensuring that third parties are covered by health and safety
management systems.
Basic duties owed to and by third parties include those of:
• Designers, manufacturers and suppliers to customers/users.
• Occupiers of premises/land to visitors.
• Contractors to clients and vice versa.
When using contractors procedures need to be adopted to ensure:
• Planning - including risk assessment.
• Selection - competent contractor.
• During contract – ensure contractor is inducted and is aware of local procedures.
• Checking of performance.
• Review of procedures.
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Summary
Consultation with Workers
ILO Occupational Safety and Health Convention (C155), Article 20 and ILO Occupational Safety and Health
Recommendation (R164) contain useful principles regarding consultation in the workplace.
• Formal consultation involves worker representatives on health and safety and the safety committee.
• Informal consultation can include discussion groups, safety circles and departmental meetings.
The health and safety practitioner has an important role to play in the consultative process.
There are behavioural aspects associated with consultation; peer group pressures and identification of potential areas
of conflict are two of these.
Positive consultation is based on the employer and worker being prepared to consider problems together, making
use of each other’s knowledge
Health and Safety Management Information System
It is common in many regions of the world for there to be legal duties (either explicit or implied) to provide
information to various categories of people.
The basis of sound health and safety information management comprises the collection of information, its
documentation and the provision of systems for cascading information to users.
A broad range of both internal and external information is needed for an effective health and safety management
information system. This includes:
• Loss event data.
• Cost data.
• Suppliers’ data.
• Results of audits and inspections.
Health and Safety Culture and Climate
Safety culture may be defined as “a system of shared values and beliefs about the importance of health and safety in
the workplace”.
Safety climate is an assessment of people’s attitudes and perceptions at a given time.
Organisational factors, e.g. training, availability of suitable equipment, behaviour of managers, etc. influence
individual behaviour.
There are many indicators that give a first impression of a company’s health and safety culture and climate. It is
possible to measure some of the indicators to gain a more accurate picture of the sense of the culture within the
organisation, using:
• Safety climate assessment tools.
• Perception or attitude surveys.
• Findings of incident investigations.
• Effectiveness of communication.
• Evidence of commitment by personnel at all levels.
Factors Affecting Health and Safety Culture and Climate
A positive health and safety culture can be promoted by various factors, such as: the commitment of management, a
high business profile, provision of information, involvement and consultation, training, promotion of ownership, and
the use of targets.
A negative health and safety culture can also be affected by various factors, such as: organisational change, lack of
confidence in an organisation’s objectives and methods, uncertainty, and inconsistent management decisions.
A change in attitudes towards the health and safety culture can be achieved by planning and communication, and
should be introduced using a gradual approach. Action to promote such a change can be direct or indirect.
© RRC International
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Exam Skills
QUESTION
By now you should be familiar with the style of NEBOSH exam questions; the next one is a straightforward 10 mark
question on health and safety culture.
Question
Outline how safety tours could contribute to improving health and safety performance and to improving
health and safety culture within a company. Discussion of the specific health and safety requirements,
problems or standards that such tours may address, is not required.
(10)
SUGGESTED ANSWER OUTLINE
Remember this is a 10 mark question so try to identify 12
points in order to gain full marks.
The Examiner would be looking for some of the following
points to be included in your answer.
Safety tours can be used in an organisation to help improve
its health and safety performance and culture by:
• Identifying compliant and non-compliant behaviours.
• Ensuring compliance with legislation and good practice.
• Seeing how effective its actions are.
• Establishing that new programmes are working as
expected.
• Identifying good practice across the company.
• Consolidating good relationships with the workforce
during tours.
• Assessing workforce behaviour on an unscheduled
basis.
• Spotting local issues.
• Identifying company-wide issues.
• Demonstrating leadership/engagement and
commitment.
• Highlighting management commitment.
• Ensuring that local remedial actions to solve issues
raised have been implemented.
• Encouraging local ownership of health and safety.
• Highlighting the importance of safety.
• Combining it with other types of tours (quality/
environmental, etc.) saving time/resources, etc.
• Sharing the findings with the workforce, showing
openness.
• Making it easier to communicate on a regular basis
with workers.
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Exam Skills
POSSIBLE ANSWER BY EXAM CANDIDATE
Safety tours can contribute to improving health and safety performance and the culture as they should be used to
identify good and poor H&S behaviours on the shop floor of the organisation. This information can be used in a
simple manner to trend on performance against set behaviours via a performance feedback sheet, such as PPE being
worn v. not worn – has it improved since last time or got worse?
The tours can be used to target new understanding or compliance with new initiatives and programmes the
company introduces and is an effective way of engaging the workforce across an organisation to support these. The
actions raised should be solved locally, visually and quickly, which demonstrates leadership and commitment of the
company and enables best practice sharing. If the safety tours are carried out by managers they can be an effective
demonstration of management commitment to safety; however this does require action to be taken as a result of the
tour.
REASONS FOR POOR MARKS ACHIEVED BY CANDIDATES IN EXAM
An exam candidate answering this question would achieve poor marks for:
• Describing how to carry out a safety tour.
• Looking at specific issues, although the question particularly said not to.
• Focusing on the timing/frequency of tours and not looking at how tours can help improve health and safety
performance.
© RRC International
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v2.1
ELEMENT
HUMAN FACTORS
7
LEARNING OUTCOMES
On completion of this element, you should
be able to demonstrate understanding
of the content through the application
of knowledge to familiar and unfamiliar
situations and the critical analysis and
evaluation of information presented in
both quantitative and qualitative forms. In
particular you should be able to:

Outline
psychological and sociological factors which
may give rise to specific patterns of safe and unsafe
behaviour in the working environment.
the nature of the perception of risk and its
Explain
relationship to performance in the workplace.

Explain
the classification of human failure.
appropriate methods of improving individual
Explain
human reliability in the workplace.
how organisational factors could contribute
Explain
to improving human reliability.

Explain
how job factors could contribute to
improving human reliability.
the principles, conditions and typical content
Outline
of behavioural change programmes designed to
improve safe behaviour in the workplace.
© RRC International
Unit IA – Element IA7: Human Factors
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| 7-1
Contents
HUMAN PSYCHOLOGY, SOCIOLOGY AND BEHAVIOUR
Meaning of Terms
Influences on Human Behaviour
Key Theories of Human Motivation
Factors Affecting Behaviour
On-Line and Off-Line Processing
Knowledge-, Rule- and Skill-Based Behaviour (Rasmussen)
Revision Questions
7-3
7-3
7-3
7-3
7-5
7-7
7-7
7-9
PERCEPTION OF RISK
Human Sensory Receptors
Process of Perception of Danger
Errors in Perception Caused by Physical Stressors
Perception and the Assessment of Risk
Perception and Sensory Inputs
Individual Behaviour in the Face of Danger
Revision Questions
7-10
7-10
7-11
7-11
7-12
7-12
7-14
7-16
HUMAN FAILURE CLASSIFICATION
HSG48, Classification of Human Failure
Contribution of Human Error to Serious Incidents
Revision Question
7-17
7-17
7-20
7-24
IMPROVING INDIVIDUAL HUMAN RELIABILITY IN THE WORKPLACE
Motivation and Reinforcement
Selection of Individuals
Revision Question
7-25
7-25
7-26
7-27
ORGANISATIONAL FACTORS
Effect of Weaknesses in the Safety Management System on the Probability of Human Failure
Influence of Safety Culture on Behaviour and Effect of Peer Group Pressures and Norms
Influence of Formal and Informal Groups
Organisational Communication Mechanisms and their Impact on Human Failure Probability
Procedures for Resolving Conflict and Introducing Change
Revision Questions
7-28
7-28
7-29
7-30
7-33
7-37
7-37
JOB FACTORS
Effect of Job Factors on the Probability of Human Error
Application of Task Analysis
Role of Ergonomics in Job Design
Ergonomically-Designed Control Systems
Relationship Between Physical Stressors and Human Reliability
Effects of Fatigue and Stress on Human Reliability
Revision Questions
7-38
7-38
7-39
7-39
7-42
7-43
7-44
7-44
BEHAVIOURAL CHANGE PROGRAMMES
Principles of Behavioural Change Programmes
Organisational Conditions Needed for Success in Behavioural Change Programmes
Example of Typical Behavioural Change Programme Contents
Revision Question
7-45
7-45
7-46
7-47
7-48
SUMMARY
7-49
EXAM SKILLS
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Human Psychology, Sociology and Behaviour
KEY INFORMATION
• Human behaviour is influenced by the personality, attitude, aptitude and motivation of the individual.
• Different theories have been proposed to help explain what motivates individuals at work.
• Experience, social background and education/training affect behaviour at work.
• Rasmussen has proposed three levels of behaviour – skill-based, rule-based and knowledge-based.
MEANING OF TERMS
A study of the human personality.
• Motivation – the factors that influence an individual
to behave in a certain way. Most people are
generally motivated to avoid accidents and ill health,
although other motivators may conflict with the
general principle. For example, wearing PPE may be
uncomfortable and interfere with the task and so may
encourage people to take greater risk by not using it.
SOCIOLOGY
KEY THEORIES OF HUMAN MOTIVATION
A study of the history and nature of human society.
There are a number of theories which have been
developed to try to explain why people do what they do.
GLOSSARY
PSYCHOLOGY
INFLUENCES ON HUMAN BEHAVIOUR
• Personality - the combination of characteristics or
qualities that form an individual’s distinctive character.
The main dimensions of personality are:
–– Extroversion/introversion – extroverts are more
outgoing than introverts.
–– Neuroticism – neurotics have high levels of anxiety.
–– Conscientiousness - such people tend to be well
organised.
–– Agreeableness – these people are more willing to
co-operate with others and avoid conflict.
–– Openness to experience – such people tend to
welcome new experiences and are more curious.
Some of these characteristics, such as
conscientiousness and agreeableness, are likely to be
positive traits in terms of health and safety.
• Attitude – reflects how a person thinks or believes
about something (often called the object of the
attitude) and this may then extend to how they behave.
For example, as a result of experiencing a workplace
transport accident a person is more likely to become
safety conscious (at least initially) in relation to work
transport hazards.
• Aptitude – the ability of an individual to undertake
a given task safely. Training and supervision usually
increase aptitude.
© RRC International
F. W. Taylor
Frederick Winslow Taylor is best known for his early 20th
century publications on improving industrial efficiency.
Taylor suggested that the reasons for inefficiency were:
• The fallacy that increased output per man will lead to
unemployment.
• Defective systems of management which make it
essential for workers to work slowly to protect their
best interests.
• Inefficient methods based on a rough and practical
approach which waste workers’ efforts.
The principles Taylor developed are stated as:
• Develop a science for each element of a man’s work, to
replace the rough and practical approach.
• Scientifically select, train and develop the workman,
instead of letting him choose his own method and train
himself.
• Co-operate with the workers to ensure that all the
work is done in accordance with the principles of the
science which has been developed.
• Management to assume responsibility for the jobs for
which they are better suited than the workman, i.e.
planning the work.
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Human Psychology, Sociology and Behaviour
Taylor’s methodology was to:
Maslow (Hierarchy of Needs)
• Design efficient methods for doing work, based on a
scientific approach, e.g. time and motion studies.
Abraham Maslow suggested five levels of human need,
which he arranged in a hierarchy.
• Set productivity goals.
Self-Actualisation
• Give financial rewards for meeting the goals.
• Train the workers to use the methods.
Taylor conducted a number of experiments which all led
to much higher productivity and wages for individuals.
The incentive used in each case was entirely financial; no
thought was given to aspects such as ‘job satisfaction’.
Esteem
Task
needs
Safety or
Security
Mayo (Hawthorne Experiments)
One of the most significant contributions to the study of
work groups took place in 1927 at the Hawthorne Works
of WEC in the USA. The Hawthorne Experiments were
originally designed as a short project to study the “relation
of quantity and quality of illumination to efficiency in
industry”.
What surprised the observers, who had thought they could
predict what was going to happen, was that output varied
with no relationship to the amount of illumination.
The observers then realised that motivation of the
individual is not just to do with money or intensity of
lighting. They started to ask themselves what motivated
individuals working in groups.
A psychologist named Elton Mayo was allowed to conduct
a series of experiments and important findings included:
• Working in a small, harmonious group can have a
significant effect on productivity.
• Having a chance to air grievances seems to be
beneficial to working relationships.
One of the essential principles here is that when you show
concern for, or pay attention to people, it can spur them
on to perform better. In other words, just the fact that the
workers being studied improved their performance. This
is known as ‘the Hawthorne effect’ or the ‘somebody
upstairs cares’ syndrome.
Social
Biological
The order in which the needs are listed is significant in two
ways:
• It is the order in which they are said to appear in the
normal development of the person.
• It is the order in which they have to be satisfied and if
earlier needs are not satisfied, the person may never
get around to doing much about the later ones.
From this theory you might expect that people in a poor
society will be mostly concerned with physiological and
safety needs, whereas those in an affluent society will
manage to satisfy those lower needs in the hierarchy
and, in many cases, will be preoccupied with the need for
self-actualisation. However, Maslow’s hierarchy stresses
that co-operation can occur only at higher levels between
mature individuals, the lower order needs leading to
conflict between individuals. Yet primitive tribes seem to
co-operate more than advanced societies, where conflict
between individuals is encouraged. This seems to suggest
that there may be a flaw in Maslow’s analysis.
The need for self-actualisation refers to the person’s need
to develop his or her full potentialities; the meaning varies
from person to person, for each has different potentialities.
For some it means achievement in literary or scientific
fields; for others, leadership in politics or the community;
for still others, merely living their own lives fully without
being unduly restrained by social conventions. ‘Selfactualisers’ are found among professors, businessmen,
political leaders, artists and housepersons.
Not all individuals in any one category are able to achieve
self-actualisation; many have numerous unsatisfied
needs and, because their achievements are merely
compensations, they are left frustrated and unhappy in
other respects.
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Human Psychology, Sociology and Behaviour
D. C. McClelland
Douglas McGregor
D. C. McClelland was, from the early 1960s, concerned
with the analysis of human needs. He concentrated on
three key needs:
Writing in the early 1960s, Douglas McGregor developed
the ideas of Theory X and Theory Y. Theory X was the
‘classical’ view that, by nature, people are lazy. They would
work ‘as little as possible for as much as possible’, i.e.
people do not really like responsibility, and they only take it
as a means of getting more money. Given a chance, people
who have been promoted would pass the responsibility
on to others but still go on collecting the higher salary.
This view goes on to argue that people are resistant to
change, and put their own interests above those of the
organisation as a whole. It shows individuals as reluctant
participants in organisational life. Organisations must offer
incentives for good work and punishment for lack of effort.
If the two are combined, it is argued, workers will function
along the lines that organisations wish them to.
• Need for Affiliation
The needs of human beings for friendship and
meaningful relationships.
• Need for Power
Some people seek power in their work situations;
they want to make a strong impression on people and
events.
• Need to Achieve
To many people the sense of ‘getting on’, progressing
or being promoted, is very important.
These three points relate to the functioning of people
at various levels of authority in an organisation. People
‘high up’ will have a strong drive for power and making
an impact; people in the middle have considerable
achievement needs and compete with each other. At the
lower levels, the drive for affiliation should be strong.
Herzberg’s Two-Factor Theory
Frederick Herzberg, writing in the late 1950s, identified
two distinct sets of needs in individuals working in
organisations: the need to avoid pain and discomfort, and
the need to develop psychologically as a person. Herzberg
identified two areas of concern for the organisation:
• Hygiene Factors
These include working conditions, company policy and
administration. If these are not adequate there will be
dissatisfaction, and work output will suffer; however if
they are satisfactory they will not motivate workers. For
example, a cold office is a cause of dissatisfaction but a
comfortable office is not a specific motivator.
• Motivators
Here, Herzberg included achievement of work tasks;
recognition by supervisors of achievement and quality
of work; the giving of increased responsibility as a
reward for successful work efforts; and the opportunity
for psychological development in the work role and
growth. Since these are the characteristics that people
find intrinsically rewarding, they will work harder to
satisfy them through their job.
In Herzberg’s model it is possible to avoid job
dissatisfaction without necessarily achieving job
satisfaction. This is possible where an organisation meets
a high level of hygiene factors, but fails to provide a high
level of motivators.
© RRC International
McGregor argued that Theory X was wrong and put
forward Theory Y, that people are often self-motivated
to work and perform best with a minimum of supervision
and control. McGregor suggests that management should
assume that in many cases workers will contribute more to
the organisation if they are treated as responsible, valuable
and industrious people. Management should reduce
controls, but retain accountability, i.e. they should replace
direction and threats with the giving of responsibility. The
workplace should allow the worker to gain satisfaction in
the pursuit of objectives to which he is committed.
FACTORS AFFECTING BEHAVIOUR
Experience
We have already noted that risk assessments should
consider groups who are particularly at risk, including the
young and inexperienced.
With increasing experience we would expect workers to
become more competent and to increase in ability to cope
with situations, but there may also be complacency and a
tendency to cut corners.
Age and experience are correlated with differences in
accident susceptibility as the following graph indicates.
Though its exact shape will vary with circumstances, the
curve will remain roughly the same.
Unit IA – Element IA7: Human Factors
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Human Psychology, Sociology and Behaviour
Accident susceptibility in relation to age and experience
Social and Cultural Background
An individual’s background will initially have a significant
effect on their behaviour. The society and culture in
which an individual is brought up teaches acceptable and
unacceptable behaviour. Being brought up in a society
where there is little work and it is a struggle to find
adequate food is likely to make people undertake tasks
with less consideration for safety compared to those from
more affluent cultures. This relates to Maslow’s hierarchy
of needs.
Education and Training
Education is often thought of as the act of acquiring
knowledge, whereas training is thought of as giving a
person more specific skills for a particular task. In many
ways the concept of safety training is a myth. Certainly the
notion of ‘bolt-on’ training to accompany job training is
at best misguided. Training which teaches workers how
to perform tasks correctly, teaches them how to perform
those tasks safely at the same time. Remember the saying:
‘the right way to do the job is the safe way to do the job’.
Safety training should be integrated into skills training
If successful both education and training will secure a
positive change in the behaviour of personnel. It is
therefore essential to identify the changes in behaviour
required before training begins and to set outcomes
which can be demonstrated after the training has been
completed. This approach allows the success of the
training to be measured and evaluation and feedback on
success to be provided.
The safety practitioner and the training manager should
ensure that safety is built into the training package when
identifying training needs. In this way, safety is further
integrated into the quality and efficiency programme and
not left outside it, where money is not available during
lean years and time is not available during boom years.
Of course, there are times when safety training has to
stand alone, such as during induction training, when new
workers should be told of specific safety procedures, e.g.
fire procedures, first-aid arrangements, etc. In general,
however, the more safety training can be integrated into
skills training, the better.
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Human Psychology, Sociology and Behaviour
ON-LINE AND OFF-LINE PROCESSING
Decisions have to be made during any working situation;
these decisions can be regarded as on-line and off-line
processing.
• On-line processing involves those decisions which
have to be made as a work process is in operation.
Since the human brain can only really deal with a few
matters at the same time, operations and the decisions
involved tend to be grouped. For example, a machine
will be set up to perform a sequence of operations.
Once set in motion, it may be difficult to stop the
operation until the sequence has been completed.
On-the-spot decisions of this type have to be made
without too much thought, and so tend to be skillbased. A wrong decision or a missed danger signal can
lead to situations where the condition is quickly made
worse. Trial and error involves on-line processing.
• Off-line processing involves those decisions that
can be made after consideration of a number of
alternatives. It is often possible to consider, and
reject, unsuitable alternatives without the need to try
them out first. Often this will involve knowledge and
intelligence. Problems occur when we assume that
we have correctly interpreted the data available and
come up with a solution to the situation. We then fail
to search for alternatives, and opt for a wrong course
of action. Other errors occur when we attempt to
solve a complicated problem mentally, when really it
requires a more detailed, written-down, mathematical
treatment, or a group decision might be more sensible.
Our mental capacity not only depends on knowledge,
intelligence and ability, but also on our fatigue levels
and our mental state at the time. It is not easy to make
correct decisions under situations of pressure, stress or
panic.
KNOWLEDGE-, RULE- AND SKILL-BASED
BEHAVIOUR (RASMUSSEN)
TOPIC FOCUS
Rasmussen’s model suggests three levels of
behaviour that explain the human error mechanisms:
• Skill-based behaviour describes a situation
where a person is carrying out a tried and tested
operation in automatic mode. A competent
cyclist can ride a bicycle without any conscious
effort, or an experienced driver can change
gear without thinking of the sequence of events
involved. Little or no conscious thought is
required; in fact, thinking about the task makes
the task less smooth and efficient, and increases
the chance of error. In this situation, errors occur
if there are any problems such as a distraction.
• Rule-based behaviour is at the next level - the
situation where the operator has available a
wide selection of well-tried routines (i.e. rules)
from which appropriate ones can be selected to
complete the task, i.e. if X happens, then I do Y.
An example is obeying local codes when driving;
if there is a red traffic signal, the usual rule is to
stop. In this situation, errors occur if the wrong
rule is applied.
• Knowledge-based behaviour is for situations
where a person has to cope with unknown
situations, where there are no tried rules or
skills. The individual, using their experience and
perhaps trial and error, tries to find a solution to
solve a novel situation. In these circumstances
the chance of error is the greatest.
Rasmussen’s model is modified by James Reason to
produce the version given in Safety at Work (7th
Edition, John Ridley & John Channing, ButterworthHeinemann Ltd, ISBN: 9780750680356) and this is
probably the most useful version since it shows the model
in the form of an algorithm (see the following figure). It
shows the individual decision-making/problem-solving
processes which lead to the action taken:
• We start in skill-based mode.
• If we do not have the requisite skill we move to rulebased behaviour.
• If no rule is available we finally resort to knowledgebased behaviour.
© RRC International
Unit IA – Element IA7: Human Factors
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Human Psychology, Sociology and Behaviour
Although all three are shown in the model as being distinct,
there is in reality a smooth transition between them and
for a more complex task all three modes of behaviour may
apply.
Dynamics of generic error-modelling system
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Human Psychology, Sociology and Behaviour
REVISION QUESTIONS
1. Define the terms ‘psychology’ and ‘sociology’.
2. Draw a diagram to explain Maslow’s hierarchy of
needs.
3. According to Rasmussen’s model, what are the
three levels of behaviour?
(Suggested Answers are at the end.)
© RRC International
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Perception of Risk
KEY INFORMATION
• Each of our senses send signals to the brain.
• We tend to screen out things we are not interested in.
• Sensory defects increase with age and ill health.
• Perceptual set is dangerous because we assume both the danger and the solution without seeing the real issues.
• Our perception of hazards can be distorted.
• Errors of perception can also be caused by physical factors such as fatigue and stress.
• An individual’s perception of a situation is based on two sources of data:
–– Information from the senses.
–– Expected information.
HUMAN SENSORY RECEPTORS
The natural senses are:
• Sight.
• Hearing.
• Taste.
Each of our other senses work by sending signals to the
brain. There is a time interval between the signal being
sent from the sensory receptor and the brain making us
aware of the situation. Remember that our senses are the
main way in which we get warning of personal danger.
Sensory Defects and Basic Screening
Techniques
• Smell.
• Touch.
(Note that there are others, such as the sense of
temperature and the sense of acceleration.)
Personal safety involves reacting to the signals sent by our
human sensory receptors to the brain. We actually see with
our brains rather than with our eyes. Our eyes send small
electrical signals to the brain, where the visual image is
constructed and interpreted.
You may have seen examples of optical illusions.
You will be aware, on occasions, of not seeing or hearing
something which was very plain to someone else. Sensory
defects increase with age and failing health. Some
people need spectacles and hearing aids, and you should
have a general idea of why this could be so. The safety
practitioner probably needs to be more concerned about
those who don’t know that they have sensory defects or
try to forget about it.
We also have the ability to shut out those things that
we are not interested in, i.e. screen out those things we
consider not worth concentrating on at the moment. Even
as you read this, you will be skipping over those ideas that
you already know, or think that you know, and perhaps
concentrating more on other items. We have to do this in
life.
• You may live within two miles of a motorway, but really
have to concentrate to hear the traffic on it.
• A worker is able to filter out background noises in a
workshop and maintain a conversation.
Optical illusion
Which centre dot is larger?
They are, in fact, the same size - your eyes see them one
way, but your brain interprets them differently.
7-10
• When driving a car or operating a work machine, or
typing on a keyboard, most of the operations are done
in ‘auto-pilot’ mode. This saves effort and allows us to
concentrate on other things, or think ahead.
This is a useful asset to have, but it is the reason for
many accidents. You cannot expect 100% concentration
on safety matters from others if you seldom give 100%
attention yourself.
| Unit IA – Element IA7: Human Factors
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Perception of Risk
PROCESS OF PERCEPTION OF DANGER
GLOSSARY
PERCEPTION
The recognition and interpretation of sensory
stimuli based chiefly on memory.
Research into perception of danger by individuals and
groups shows that there is a clear distinction between how
we perceive risks to personal safety, dangers to health, and
dangers to society. Individuals who take part in hazardous
sports and activities may be very reluctant to take even a
small risk in the work situation.
The factors involved in perception are:
• Signals from the Sensory Receptors
Our eyes, ears, nose, touch and perhaps taste make
us aware of the situation, but these signals can be
misleading if we suffer from a sensory defect.
• Expected Information from the Memory
We have an expectation of what to see and hear; this
signal is from the memory. We sometimes see things
that are not there, and don’t see things that are. This
signal can also be misleading, particularly if it is affected
by stress, alcohol, drugs, fatigue, or just familiarity.
These two signals combine to give us a ‘picture’ of the
hazard situation, which is then processed by the brain. We
then take, or decide not to take, action.
Perceptual Set
This is sometimes called a ‘mindset’. We have a problem and immediately perceive not only the problem, but also
the answer. We then set about solving the problem as we
have perceived it. Further evidence may become available
which shows that our original perception was faulty, but
we are now so pleased with our intelligent solution that we
fail to see alternative causes and solutions. This is a basic
cause or factor in many accidents and disasters.
Students often get such mindsets when answering
examination questions and assignments. You have
prepared yourself well for a particular type of question.
This seems to be there on the examination paper and you
immediately set about writing the answer. Later, when
discussing this with others or rereading the question,
you wonder how you could have missed the point. The
examination committee spent a great deal of effort to
make it perfectly clear what was needed, but all to no avail.
The same thing can happen in work situations. For
example, a signalman was expected to check that there was
a red light at the back of every train which passed his signal
box. He had never seen a situation where this was not so
in the ten years that he had been doing his job. However,
on one occasion part of the train had become uncoupled,
but he distinctly remembered checking and ‘seeing’ the red
light as the train passed. A following train collided with the
part of the train that had become uncoupled. This was a
typical case of mindset or perceptual set.
Perceptual Distortion
Everyone’s perception of hazard is faulty because it gets
distorted. Things that are to our advantage always tend to
seem more right than those that are to our disadvantage.
Management generally tend to have a different perception
of hazard from that of workers. When it affects work rates,
physical effort, or bonus payments, workers also suffer
from perceptual distortion.
ERRORS IN PERCEPTION CAUSED BY
PHYSICAL STRESSORS
In examining the cause of errors in perception, we
also need to consider the effects of fatigue, overwork,
overtime, stresses from the workplace, and stresses from
home and outside activities. Shift work is a major factor.
Our bodies operate best when we have a regular routine.
Human beings have an inbuilt clock (the Circadian Cycle)
and the pattern of work, rest and sleep is upset by a
change of work pattern. It is even possible that we are
locked into a seven-day pattern.
Perception is affected by having to keep awake and alert
when the body is saying that it is time to sleep. Fatigue is
more than tiredness of the muscles and the mind; there is
a physical, mental and psychological dimension.
Fatigue can lead to errors in perception
HINTS AND TIPS
Always answer the question which has been set, not
the one you wish had been set!
© RRC International
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Perception of Risk
PERCEPTION AND THE ASSESSMENT OF
RISK
If there are problems in our basic perception of a situation,
then there are going to be errors in our perception of
risk. In assessing a risk there is safety in numbers. My
faulty perception of a risk could be corrected by another
person’s clearer perception of an issue. Perception also
depends upon knowledge and experience. A group will
usually have more to contribute than an individual.
Perception and the Limitations of Human
Performance
Even when we have achieved perfection in the realm of
perception – and this is very unlikely – we still have to
put the solution into effect. As human beings we have
limitations in knowledge, strength, physical and mental
ability. We have plenty of excuses for getting things wrong.
The major problem is that legislation, the courts, the media
and the public at large expect perfection in the realm of
health and safety. Representatives of the media will ask:
“Can you guarantee that this will never happen again?”
when investigating an industrial accident situation. We
can only say something like: “We have learned from this
mistake and we consider the possibility as now remote”.
Filtering and Selectivity as Factors for
Perception
Filtering and selectivity are vital human activities, since we
often tend to do many activities in ‘auto-pilot mode’. From
a safety point of view, however, the process of filtering and
selectivity presents a danger. While concentrating on a
particular topic, to the selective exclusion of others, we can
easily miss a vital signal which should have warned us of
danger. However, we do tend to notice changed situations.
Danger signals and warnings are more likely to be noticed
if they involve loud bells or klaxons and flashing rather than
fixed lights.
PERCEPTION AND SENSORY INPUTS
The Hale and Hale Model
An article by Professor A. R. Hale and M. Hale, Accidents
in Perspective, was published by the National Institute of
Industrial Psychology in 1971. This includes a model of
accident causation which includes the idea of perception.
Professor Hale has written one of the chapters in Safety
at Work by Ridley (Ed.), in which a version of this diagram
is shown and explained. Professor Hale suggests that
accident research dealing with accident proneness and
unicausality shows confused thinking. He suggests that
his model allows any accident to be investigated and the
root cause determined by finding the place, or places, on
the model which represent(s) the major source of error.
It follows that, if you have correctly determined the cause
of the accident, then it is easier to find the solution. In this
case we are looking for human factors.
Our senses are continuously receiving information and the
brain is processing it. However, we cannot keep our mind
continuously on all that is coming to us: we use a filter
mechanism.
Information passed to higher levels of management is also
filtered. From all the information available, only the vital
elements are passed on.
In much the same way, we tend to be continuously
screening out those items that are not of immediate
interest. In a noisy workshop, an operator will tend not
to hear the background noise, but only those factors that
are of interest to his particular job. Although we see all in
front of us, we can concentrate on one particular subject
and filter out other matters. We don’t hear a constantly
ticking clock, but would be immediately aware if it stopped.
If you are able to ‘speed read’ then you would not see each
individual word, but would quickly scan a page, only seeing
those word forms which convey vital information. For
instance, if you were looking for some information about
‘filtering’, you could rapidly scan an article and be stopped
by the occurrence of the word ‘filter’, without reading the
whole article.
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Perception of Risk
Accident causation model according to Hale and Hale
An individual’s perception of a situation is based on two
sources of data:
• Information from the senses.
• Expected information.
Both of these sources could be incomplete or incorrect.
Physical defects of sight or hearing can affect the
presented information, while fatigue, stress, or drugs can
alter the expected information. From past experience,
or some stereotyped expectation, we sometimes see a
situation other than the actual one.
© RRC International
Other errors can occur in decisions as to possible actions
and the internal processing of information. This also
involves some cost/benefit decision. Errors can occur
because of our lack of knowledge, our ideas of possible
actions and in our estimate of effects of any action.
The action, whether good or bad, will affect the situation
and so produces a feedback loop. New information will
be presented and there is a possibility of a trial and error
situation.
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Perception of Risk
INDIVIDUAL BEHAVIOUR IN THE FACE OF
DANGER
Model
The Hale and Glendon Model
• Accident proneness model.
Here is some brief information regarding this model.
System Approach
A system comprises an organisation of a number of
interrelated elements interacting with each other within
a system boundary. In these systems the elements are
usually hardware (machines, buildings, materials) and
people, which interact physically or through the exchange
of information governed by rules and procedures. The
system boundary may be the factory walls, those of the
department, the confines of the car someone is driving,
or some other boundary appropriate to the level of the
analysis undertaken. Outside the boundary is the system
environment. The system has a number of goals or
objectives that it is attempting to achieve, e.g. making a
profit, producing a given output, or getting from A to B
without having an accident. Implicit in the existence of
goals is the need for a feedback mechanism, whereby the
system compares its current position and state with those
goals in order to guide that progress.
The book looks at the following models:
• Engineering models, e.g. fault tree analysis – this does
not work well for humans because they have too many
failure modes.
• Interactive models, e.g. Hale and Hale involving
perception.
The models suggested by Hale and Hale, and by
Rasmussen and Reason, are combined to produce the
model of behaviour in the face of danger given in the
following figure. This diagram is also reproduced in Ridley.
The figure is in the form of an algorithm and is relatively
easy to follow. You start at the bottom centre with the
OBJECTIVE DANGER. A solution to the situation is sought
using increasing levels of activity.
An open system communicates across the system
boundary with its environment and with other systems.
Some Definitions
• Danger: a situation or system state in which there is a
reasonably foreseeable potential for unintended harm
to human or physical elements in the system.
• Hazard: a specific agent which in defined
circumstances would cause damage to a system
element. Every dangerous situation therefore contains
one or more hazards.
• Risk: the probability that damage of a specific type to
specified system elements will occur in a given system
over a defined time period.
• Harm: damage to a system element so that it can no
longer carry out its system function and requires repair,
treatment or rehabilitation over a significant period.
• Accident: the process of occurrence of unintended
harm where exposure to the hazard results immediately
in harm.
• Safety: the converse of danger; a situation in which
the system is under control and the harm process has
not begun.
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v2.1
Perception of Risk
Behaviour in the face of danger model
(Reproduced from Individual Behaviour in the Control of Danger by A. R. Hale and A. I. Glendon (1987) with kind permission from Elsevier Science - NL,
Sara Burgerhartstaat 25, 1055 KV Amsterdam, The Netherlands)
© RRC International
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Perception of Risk
REVISION QUESTIONS
4. Outline, with examples, how the human sensory
receptors react to danger.
5. Explain how failings in the human sensory and
perceptual process may lead to accidents.
(Suggested Answers are at the end.)
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Human Failure Classification
KEY INFORMATION
• Human failure can be classified as errors and violations.
• Errors are actions or decisions which were not intended, and involved a deviation from an accepted standard
which led to an undesirable outcome.
• Errors can be split into three types: slips, lapses and mistakes.
• Violations are a deliberate breaking of safety rules.
• There are three types of violation: routine, situational and exceptional.
• The study of actual incidents gives us insight into the way that human error can contribute to major disasters.
HSG48, CLASSIFICATION OF HUMAN
FAILURE
The UK’s HSE publication, Reducing Error and Influencing
Behaviour, HSG48, identifies two types of predictable
human failure: errors and violations.
Errors
Errors are actions or decisions which were not intended
and involved a deviation from an accepted standard which
led to an undesirable outcome.
Errors can be further split into several types (based on the
Rasmussen’s skill-, rule- and knowledge-based behaviour
theory).
Errors
Skill-based
Errors
Slips of
Action
Mistakes
Lapses of
Memory
Rule-based
Mistakes
Knowledgebased
Mistakes
Types of error
© RRC International
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Human Failure Classification
TOPIC FOCUS
Skill-Based Errors
(Note: The term “skill” as used by Rasmussen (and here) is not used in the way people generally understand it.)
These types of errors occur in very familiar tasks which require little conscious attention, e.g. an experienced driver
driving on a familiar road. Errors can occur when we are distracted or interrupted.
• Slips – failures in carrying out the actions of a task. Examples include:
–– Performing an action too soon or too late.
–– Leaving out a step or series of steps from a task.
–– Carrying out an action with too little or too much strength.
–– Performing the action in the wrong direction.
–– Doing the right thing but with regard to the wrong object (or vice versa).
• Lapses – forgetting to carry out an action, losing a place in a task or forgetting what we had intended to do.
These are often linked to interruptions or distractions. Using a simple checklist can help to reduce the likelihood
of lapses occurring.
Possible prevention strategies for skill-based errors include: verification checks, such as checklists; feedback warning
signals if wrong action selected; design of routines to be distinct from each other; and supervision.
Mistakes
These are where we do the wrong thing believing it to be right. The failure involves our mental processes that control
how we plan, assess information, decide on our intentions and judge consequences.
• Rule-Based Mistakes
These occur when our programme is based on remembered rules or procedures. We have a strong tendency to
try to use or select familiar rules or solutions. Errors occur if:
–– No routine is known which will solve the new situation, so we don’t know what to do.
–– We try to apply the usual remembered rules and familiar procedures because of familiarity with similar
problems from previous experience, even when they are not appropriate.
–– The wrong alternative is selected, or there is some error in remembering or performing a routine.
Possible prevention strategies include: simple, clear rule sets; system designed to highlight unusual or infrequent
occurrences; clear presentation of information.
• Knowledge-Based Mistakes
These may occur in unfamiliar situations where no tried and tested rule exists. They are often related to
incomplete information being available or misdiagnosis where, when facing new or unfamiliar situations, we are
trying to solve problems from first principles. Errors occur when:
–– Some condition is not correctly considered or thought through or when the resulting effect was not expected
or is ignored.
–– There is insufficient understanding or knowledge of the system.
–– There is insufficient time to properly diagnose a problem.
Possible prevention strategies include: training; supervision; use of checking systems; provision of sufficient time
and knowledge.
Violations
Violations are a deliberate deviation from a rule or
procedure, e.g. driving too fast or removing a guard from a
dangerous piece of machinery, both of which increase the
risk of an accident. Health risks are also increased by rule
breaking, e.g. a worker who does not wear ear defenders
in a noisy workplace increases their risk of occupational
deafness.
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TOPIC FOCUS
There are three types of violation:
Routine
A routine violation is the normal way of working within the work group and can be due to a number of (sometimes
overlapping) factors, including:
• Cutting corners to save time and/or energy – which may be due to:
–– Awkward, uncomfortable or painful working posture.
–– Excessively awkward, tiring or slow controls or equipment.
–– Difficulty in getting in or out of maintenance or operating position (posture).
–– Equipment or software which seems unduly slow to respond.
–– High noise levels which prevent clear communication.
–– Frequent false alarms from instrumentation.
–– Instrumentation perceived to be unreliable.
–– Procedures which are hard to read or out of date.
–– Difficult to use or uncomfortable personal protective equipment.
–– Unpleasant working environments (dust, fumes, extreme heat/cold, etc.).
–– Inappropriate reward/incentive schemes.
–– Work overload/lack of resources.
• Perception that rules are too restrictive, impractical or unnecessary (particularly where there has been a lack of
consultation when they were drawn up).
• Belief that the rules no longer apply.
• Lack of enforcement of the rules (e.g. through lack of supervision/monitoring/management commitment). In
certain cases the violation may even be sanctioned by management “turning a blind eye” in order to get the job
done (related to cutting corners, see above).
• New workers starting a job where routine violations are the norm and not realising that this is not the correct way
of working. This in itself may be due to culture/peer pressure or a lack of training.
Situational
Situational violations are where the rules are broken due to pressures from the job, such as:
• Time pressure.
• Insufficient staff for the workload.
• The right equipment not being available.
• Extreme weather conditions.
Risk assessments should help to identify the potential for such violations, as will good two-way communications.
Exceptional
Exceptional violations rarely happen and only occur when something has gone wrong. To solve a problem, workers
believe that a rule has to be broken. It is falsely believed that the benefits outweigh the risks. Means of reducing such
violations could include:
• Training for dealing with abnormal situations.
• Risk assessments to take into account such violations.
• Reduction of time pressures on staff to act quickly in new situations.
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Unit IA – Element IA7: Human Factors
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Human Failure Classification
HSG48 provides a powerful model showing the type of
human errors and violations that can be predicted from
consideration of organisational, job and individual factors.
Such a model can be used both in risk assessments and
accident investigations to suggest the control measures
required to prevent either an occurrence or a recurrence.
MORE…
You can download Reducing Error and Influencing
Behaviour, HSG48, from the HSE website at:
www.hse.gov.uk/pubns/priced/hsg48.pdf
CONTRIBUTION OF HUMAN ERROR TO
SERIOUS INCIDENTS
No study of human error will be complete without some
consideration of major incidents. In each case you need to
consider the part played by human error. An investigation
usually apportions blame, but although some blame will be
attached to those who are directly involved, the majority
of the blame is usually placed on those in responsible
management positions. Safety practitioners usually carry
some responsibility as well.
Seveso (near Milan, Italy), 1976
This disaster is named after the village near Milan, Italy,
whose inhabitants were so badly affected. It involved
the release of a cloud containing, amongst other
things, the highly toxic and carcinogenic compound,
2,3,7,8-tetrachlorodibenzodioxin (also called simply
“dioxin”) from a chemical plant run by Icmesa Chemical
Company. The plant at Seveso was running a process
to manufacture pesticides and herbicides. Dioxin was
normally produced as a by-product of the reaction,
but only in very small quantities if the temperature was
controlled below critical levels. The incident happened
at the weekend, when the plant was shut down (required
by Italian law). However, the plant had been shut down
partway through production so that the steam-heated
vessel had been left full of reactants. It is thought that,
as other processes in the plant were shut down, the
steam temperature rose. A reaction occurred which
eventually overheated and became a thermal runaway
(the reactor had no automatic cooling). The ensuing very
high temperatures produced large quantities of dioxin as
a by-product. The pressure increased greatly, rupturing a
bursting disc off the reaction vessel and resulting in the
release of most of its contents into the atmosphere via a
vent set at roof level. Approximately 6 tonnes of reactants
(including sodium hydroxide) and an estimated 1 – 2 kg
of highly toxic dioxin were dispersed into the atmosphere.
The cloud drifted to the nearby village of Seveso.
7-20
The seriousness of the effects on the population
was not immediately recognised. Dioxins are fatsoluble. Consequently they have a strong tendency
to bioaccumulate (i.e. accumulate in the body from
the surroundings and remain in the body for some
considerable time). Approximately 2000 people were
treated for dioxin poisoning. The area was made
uninhabitable due to contamination. Recorded health
effects included birth defects, skin disease (chloracne) and
liver cancer.
Factors contributing to the accident:
• The legislative environment – well-intentioned law
regarding weekend plant shutdowns that did not allow
management discretion to complete a batch process.
• The process was stopped at an unusual stage (never
before stopped at this stage).
• No systematic hazard analysis, such as HAZOP, had
been carried out on the process – the potential
consequences would almost certainly have been picked
up if a HAZOP had been conducted.
• Inadequate reaction/process control: no cooling
or stirring when the process was stopped for the
weekend; inadequate sensors for measuring critical
process parameters; lack of automatic systems; no
catch-pot system to intercept toxic by-products instead they were vented directly to atmosphere when
the bursting disc failed during overpressure.
• No emergency response plan; indeed no safety
management system.
The disaster led to the creation of new laws throughout
Europe on the control of such major accident hazard sites.
| Unit IA – Element IA7: Human Factors
© RRC International
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Human Failure Classification
Chernobyl (Ukraine), 1986
Factors that led to the accident:
Chernobyl is situated just north of Kiev, in Ukraine. At the
time, Ukraine was part of the Soviet Union. The power
station had several reactors and the accident happened
with reactor number 4. This accident occurred during
experiments carried out during a planned shut-down.
The proposed experiments were reasonable, but there
were a number of errors of judgment that occurred. The
sequence of events is quite complicated so only a short
summary is provided here, as we are focusing more on
lessons to be learned.
• The reactor design was flawed – there are inherently
safer designs. There was also no trip system to prevent
running at low outputs. There was an automatic shutdown system to insert all the control rods to shut down
the reactor but this had been disabled (see earlier).
In this design of reactor, called a Boiling Water Reactor,
the nuclear fuel is held in zirconium alloy tubes which
are embedded in a block of graphite (which acts as a
“moderator” and enables the desired nuclear reaction to
take place). Boiling water is passed through these tubes as
a coolant. Control rods (of which there were about 200
in this design) control the rate of the nuclear reaction (by
absorbing neutrons) as they are moved in (and out) of
the graphite block. They can be used to shut down the
reactor under emergency conditions. Even if the reactor
is shut down, residual heat is still produced by the normal
radioactive decay. Because of this, cooling must always be
maintained. This nuclear core was encased in a concrete
shield.
Management wanted to conduct several repeats of the
experiment. In between these experiments, the reactor
should have been shut down. However, because time was
short, they had decided instead to simply take the reactor
down to low output conditions between experiments (it
would otherwise take far too long to bring the reactor
on-line from a shut down). This would be achieved by
lowering control rods into the reactor core. However, it
was well known that this design of reactor was unstable
under low output conditions (this design of reactor is
not used outside of the former Soviet Union). Prolonged
running at low output levels produces a build up of a
by-product (Xenon) which actually “poisons” the reactor,
greatly reducing its output. Consequently, it appears that
the output fell quicker and to much lower levels than
intended. In an attempt to correct the situation, control
rods were raised and an automatic shut-down system
(which operates under fault conditions) was disabled. At
first, power began to rise again but then suddenly surged
uncontrollably. By now, around six control rods remained in
the core – the minimum should be 30.
• Basic safety rules were not clearly stated (there
should have been an instruction to forbid running at
low output levels) and normal safety rules were not
followed during the experiment. (It was important to
keep the reactor output above a minimum of 20%, as
below this it could become unstable. In the experiment,
it went down to around 6% output.) Also, at least
30 control rods should always have been in place
as a minimum – instead, all but six were removed.
Protective systems were disabled – the automatic trip
which would have shut down the reactor under fault
conditions was isolated.
• Poor safety culture – turning a blind eye to rule
breaking; lack of proper authorisation of the
experiments (at the appropriate management level);
lack of inspection/regulation; culture of “sloppiness”.
• Lack of proper planning of the experiment – in
particular, consideration of how things might go wrong
and their potential consequences.
• Poor understanding of the consequences of their
actions by the operators (e.g. they did not understand
the importance of keeping a minimum number of
control rods in place to control the reactor).
Despite activating emergency manual shutdown (manual
insertion of the control rods), it was too late. The reactor
core temperature had risen enormously (heat output
increased 100 fold in one second!), rising to around
4000°C. Eventually, several explosions shattered the
reactor roof, allowing radioactive material to be released
into the atmosphere and, eventually, spread all over the
world’s northern hemisphere.
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Human Failure Classification
Three Mile Island (USA), 1979
Bhopal (India), 1984
Three Mile Island nuclear plant is near Middletown, in
Pennsylvania, USA. This is another nuclear incident, though
with far less serious consequences than that of Chernobyl.
Though the reactor core went into meltdown, there were
only small releases of radioactivity and no deaths/injuries.
The reactor in this case was of a different design to that
of Chernobyl – it was a Pressurised Water Reactor (PWR),
which is a very common design throughout the world
(other than in the former Soviet Union). In this design, the
primary coolant water is kept pressurised so that it does
not boil. The primary coolant water passes the heat on to
a secondary water system (via a heat exchanger), which is
allowed to boil – the steam driving a turbine to generate
electricity.
Bhopal is in India. A Union Carbide chemical plant was
situated here. The accident involved a leak of some 25
tonnes of highly toxic methyl isocyanate (MIC) from a
storage vessel. The cloud of MIC dispersed and killed
around 2000 people and injured another 200000. These
were official figures - estimates put the real number of
fatalities closer to 10000.
To summarise, the incident started with a failure of the
secondary circuit – which prevented heat removal. This
caused the reactor to shut down and the pressure in the
primary circuit to increase. This in turn triggered the
opening of a pressure relief valve which, unfortunately,
stuck open instead of closing again when the pressure
had reduced. As it happened, the signals on the operating
consoles indicated that the valve had shut (the lamp was
triggered by the circuit signal to the valve rather than the
actual valve position). The continued escape of the coolant
through the valve allowed the core to overheat.
Coupled with this was the confusing instrumentation
available to the operators. There was no coolant level
indicator – instead it was inferred from levels elsewhere
in the system (but these levels had actually been raised by
bubbles of steam). Alarms began to sound but at that stage
the nature of the unfolding incident was not recognised
as a “loss of coolant” incident. Immediate actions included
reducing the coolant flow in the core (their training had
emphasised the danger of too much coolant and, of
course, they believed, from the instrumentation, that the
pressure relief valve was shut); this made things worse. If
they had done nothing, the plant would have cooled down
on its own. Instead, the core continued to overheat and
the fuel began to melt.
Factors that led to the accident:
• Operators were under considerable stress – many
alarms were going. They had incorrectly diagnosed
what they thought was the problem and stuck to a
course of action, despite apparently overwhelming
evidence to the contrary.
• Operator training was inadequate. Operators of
complex plant cannot just be given a series of
instructions to follow. Things are bound to go wrong
outside of this. They also need to understand the
principles of the process, and be trained in diagnosing
problems (both foreseen and unforeseen) and in the
use of diagnostic aids.
• The crucial indicator (of the status of the pressure relief
valve) was wrong. This did not look at the status of the
relief valve directly – it should have done.
7-22
MIC was used by Union Carbide as an intermediate in
the manufacture of an insecticide. The storage vessel
containing MIC became contaminated with large quantities
(tonnes) of water and chloroform. There is considerable
debate on how this could have happened, but one serious
possibility is that it was deliberate sabotage. This initiated
a thermal runaway reaction (water reacts violently with
MIC), which caused the pressure and temperature
to increase. Instruments indicating the high pressure
and temperature were ignored (they were considered
unreliable). The growing vessel pressure was vented to
atmosphere by the operation of a pressure relief valve.
Because of the toxic nature of this compound, it should
never have been allowed to be vented into the open, or
at least discharge should have been kept to a minimum.
Protective systems installed in/on the storage vessel
included a refrigeration system (which would have cooled
the reaction), a scrubber (to absorb much of the vapour
discharged) and a flare stack (which would have burnt
off any remaining vapour). However, none of these were
working at the time.
Factors that contributed to the accident:
• The large inventory of the intermediate. This was
unnecessary. It was not a raw material nor a product
but an intermediate. It should not have been stockpiled
but instead used in the next stage of the process as it
was produced, or at least kept to a minimum.
• The plant was located next to a sizable population. A
shanty town (temporary housing) had been allowed to
grow up very close to the plant. This should not have
been allowed - either by planning legislation or by
Union Carbide buying and fencing off the surrounding
land.
• Protective systems were not kept in working order.
Even if they had been working, they are likely to have
been inadequate to control a thermal runaway of this
magnitude (but would certainly have reduced the
effects).
• No systematic study (such as HAZOP) undertaken to
identify any suggested contamination routes (it is well
known that water and MIC react together violently)
and therefore implement measures to eliminate the
likelihood of this happening.
• Process parameter instrumentation was poorly
maintained and unreliable - led to early signs of
pressure/temperature increase being ignored.
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Human Failure Classification
• There is some suggestion that managers and operators
at the plant had insufficient experience and knowledge.
The plant was a joint venture – part owned by Union
Carbide and part owned locally.
• Poor emergency planning.
Buncefield (UK), 2005
The Buncefield incident was a major fire caused by a series
of explosions in the early hours of Sunday 11 December
2005 at the Buncefield Oil Storage Depot, Hemel
Hempstead, Hertfordshire, UK. At least one of the initial
explosions was of massive proportions and there was a
large fire which engulfed a large proportion of the site.
Over 40 people were injured but there were no fatalities.
Significant damage occurred to both commercial and
residential properties in the vicinity and a large area around
the site was evacuated on emergency service advice. The
fire burned for several days, destroying most of the site and
emitting large clouds of black smoke into the atmosphere.
The cause of the incident was the formation of a
flammable mixture of petrol, or similar spirit, and air that
ignited, leading to the explosions and fire.
The sequence of events was as follows:
10 December 2005: Around 19.00, Tank 912 in bund A
at the Hertfordshire Oil Storage Ltd (HOSL) West site
started receiving unleaded motor fuel from the T/K South
pipeline, pumping at about 550m3/hour.
11 December 2005: At approximately midnight, the
terminal was closed to tankers and a stock check of
products was carried out. When this was completed at
around 01.30, no abnormalities were reported.
From approximately 03.00, the level gauge for Tank
912 recorded an unchanged reading. However, filling of
Tank 912 continued at a rate of around 550m3/hour.
Calculations show that at around 05.20, Tank 912 would
have been completely full and starting to overflow.
Evidence suggests that the protection system which should
have automatically closed valves to prevent any more filling
did not operate.
From 05.20 onwards, continued pumping caused fuel to
cascade down the side of the tank and through the air,
leading to the rapid formation of a rich fuel/air mixture
that collected in bund A.
At 05.38, CCTV footage shows vapour from escaped fuel
starting to flow out of the north-west corner of bund A
towards the west. The vapour cloud was about 1m deep.
At 05.46, the vapour cloud had thickened to about 2m
deep and was flowing out of bund A in all directions.
By 05.50, the vapour cloud had started flowing off site
near the junction of Cherry Tree Lane and Buncefield
Lane, following the ground topography. It spread west into
Northgate House and Fuji car parks and towards Catherine
House.
At 06.01 the first explosion occurred, followed by further
explosions and a large fire that engulfed over 20 large
storage tanks. The main explosion event was centred on
the car parks between the HOSL West site and the Fuji
and Northgate buildings. The exact ignition points are not
certain, but are likely to have been a generator house in
the Northgate car park and the pump house on the HOSL
West site.
At the time of ignition, the vapour cloud extended to the
west, almost as far as Boundary Way in the gaps between
the 3-Com, Northgate and Fuji buildings; to the north
west it extended as far as the nearest corner of Catherine
House. It may have extended to the north of the HOSL site
as far as British Pipelines Agency (BPA) Tank 12 and south
across part of the HOSL site, but not as far as the tanker
filling gantry. To the east it reached the BPA site.
There is evidence suggesting that a high-level switch, which
should have detected that the tank was full and shut off
the supply, failed to operate. The switch failure should have
triggered an alarm, but that too appears to have failed.
The UK Health Protection Agency and the UK Major
Incident Investigation Board provided advice to prevent
incidents such as these in the future. The primary need
was for safety measures to be in place to prevent fuel
from exiting the tanks in which it is stored. Added safety
measures were needed for when fuel does escape, mainly
to prevent it forming a flammable vapour and to stop
pollutants poisoning the environment.
Piper Alpha Oil Rig Explosion
(North Sea), 1988
On 6 July 1988, there was a disastrous fire on the Piper
Alpha oil rig in the North Sea; 167 men were killed and
many who survived were injured and traumatised.
The rig was operated by Occidental Petroleum
(Caledonian) Limited. Piper Alpha was part of a linked
operation involving four rigs. The operation involved gas,
compressed gases and crude oil. The various operations on
Piper Alpha were in modules which were stacked on top of
each other. The helicopter landing pad was on the highest
level, and on top of the main accommodation module.
Two-hundred and twenty-six men were on the platform;
62 were working the night shift, and the majority of the
others were in the accommodation modules.
Between 05.50 and 06.00, the pumping rate down the
T/K South pipeline to Tank 912 gradually rose to around
890m3/hour.
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Human Failure Classification
At 22.00 hours there was an explosion followed by a
fireball which started from the west end of B module. This
was quickly followed by a series of smaller explosions. The
emergency systems, including fire water systems, failed
to operate. Three mayday calls were sent out, and the
personnel assembled on D deck. The radio system and the
lighting then failed.
At 22.20 hours there was a rupture of the gas riser of
the Tartan supply (another rig – but the pipeline was
connected to Piper Alpha), followed by another major
explosion, with ignition of gas and crude oil.
At 22.50 there was a further explosion with a collapse of
much of the structure.
There was a mass of photographic evidence, taken from
the other rigs and ships in the area, but some problem
in fixing the exact time of each. The enquiry was very
thorough, but unable to come up with clear conclusions.
Gas detection equipment was working, but some water
systems had been turned off, and some welding operations
were in progress. The report criticised the platform design,
and the lack of safety systems. It called for major changes
in disaster planning and auditing.
The key factors leading to the disaster included:
• Failure in the permit-to-work system.
• Design failure in that the rig containment wall was fireresistant but not blast-resistant.
• Other rigs did not shut down and continued to feed
into Piper Alpha, fuelling the fire.
• Inadequate emergency procedure for rig evacuation.
Texas City (USA), 2005
On 23 March 2005, a series of explosions occurred during
the restarting of a hydrocarbon isomerisation unit at BP’s
Refinery in Texas City, Texas, USA. A distillation tower
flooded with highly flammable liquid hydrocarbons and
was over pressurised, causing a release of liquid from the
top of the stack and a cloud of flammable vapour to form
over the refinery. A diesel pickup truck that was idling
nearby ignited the vapour, initiating a series of explosions
and fires that swept through the unit and the surrounding
area. Most of the 15 people killed were in administration
trailers placed too close to the tower, which instantly
disintegrated. A further 180 people were injured, 70
vehicles were damaged and windows shattered as far away
as three quarters of a mile.
The US Chemical Safety and Hazard Investigation Board
investigation found that approximately 7600 gallons
(28800 litres) of flammable liquid hydrocarbons - nearly
the equivalent of a full tanker truck of gasoline - were
released from the top of the blow-down drum stack in just
under two minutes. The ejected liquid rapidly vaporised
due to evaporation, wind dispersion, and contact with the
surface of nearby equipment. High overpressures from
the resulting vapour cloud explosion totally destroyed
13 trailers and damaged 27 others. People inside trailers
were injured as far as 500 feet (152 metres) away from
the blowdown drum, and trailers nearly 1000 feet (305
metres) away sustained damage.
The distillation tower overfilled because a valve allowing
liquid to drain from the bottom of the tower into storage
tanks was left closed for over three hours during the
start-up on the morning of 23 March, which was contrary
to unit start-up procedures. The investigation found that
procedural deviations, abnormally high liquid levels and
pressures, and dramatic swings in tower liquid level were
the norm in almost all previous start-ups of the unit since
2000. Operators typically started up the unit with a high
liquid level inside and left the drain valve in manual - not
automatic - mode to prevent possible loss of liquid flow
and resulting damage to a furnace that was connected to
the tower. These procedural deviations - together with
the faulty condition of valves, gauges, and instruments on
the tower - made the tower susceptible to overfilling. The
investigation identified numerous failings in equipment,
risk management, staff management, working culture at
the site, maintenance and inspection, and general health
and safety assessments.
REVISION QUESTION
6. How did human error contribute to the Three
Mile Island incident?
(Suggested Answer is at the end.)
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| Unit IA – Element IA7: Human Factors
© RRC International
v2.1
Improving Individual Human Reliability in the Workplace
KEY INFORMATION
Human reliability may be improved by:
• Incentive and reward schemes.
• Increasing job satisfaction.
• Appraisal schemes.
• Selecting appropriate individuals for the job:
––
––
––
––
––
Matching skills and aptitudes.
Training and competence assessment.
Ensuring fitness for work.
Health surveillance.
Support for ill health including stress-related illness.
MOTIVATION AND REINFORCEMENT
Workplace Incentive and Reward Schemes
GLOSSARY
INCENTIVE
An inducement that provides a motive for someone
to do something, usually in the form of some sort of
reward for achieving a particular goal or milestone.
(Note that the words ‘incentive’ and ‘reward’ in this
context are routinely used interchangeably.)
Workplace incentive or reward schemes can be a good way
of motivating workers to focus on the job and conform to
the organisational goals. The incentive encourages workers
to work harder in order to receive a payment or benefit.
For example, achieving a set target or exceeding that target
may mean that individuals receive a financial bonus or a
prize. The scheme may operate on an individual basis or
as a team effort, in which case the incentive would be for
the team to achieve the target. The incentive scheme may
be set up so that a winning team or individual is identified
every month, for example, and the winner is given a prize.
This type of incentive motivates individuals to work harder,
but also motivates teamwork.
Some pay schemes work by paying a very low actual salary,
but having bonus payments which are paid when targets
are met, e.g. sales jobs. The motivation to sell more is
clearly through the financial gain.
Piecemeal work, i.e. where workers are paid per work
unit completed, (e.g. for each sheep sheared) encourages
individuals to work quickly so that they can earn more
money. This may have implications with respect to safety
as the workers are not encouraged to necessarily consider
safety as their first priority.
© RRC International
Incentive schemes aimed at improving safety are more
difficult as they may need to monitor the results over a
reasonable time period, e.g. one year. Incentive schemes
can often lose their momentum and their effectiveness
over time. For this reason, it is important to either keep the
time periods short or continue to keep the momentum
high.
Incentive schemes for safety may relate to obtaining
improved ‘scores’ during routine audits or inspections. This
type of incentive would be aimed at ensuring all members
of the workforce made their work area as safe as possible
and that work was carried out in a safe manner. Avoid
incentives aimed at reducing accidents specifically, i.e.
where measurement would be a decrease in accident rates,
as this may result in under-reporting of accidents in order
to obtain the incentive.
Job Satisfaction
For some people, job satisfaction is all that they require to
be motivated. Job satisfaction is also very individual to each
person:
• Some people are satisfied with a good working
environment and regular rest breaks.
• Other people require challenging, stimulating work
where they receive positive feedback.
You will remember that Herzberg identified particular
motivating factors which, when present, increase
satisfaction from work and provide motivation towards
superior effort and performance. These include
recognition, responsibility, achievement, advancement and
the work itself, and are distinct from other factors that
increase dissatisfaction when absent, but when present, do
not result in positive satisfaction and motivation. Herzberg
termed these “hygiene” factors. They include: type of
supervision, salary/wages, working conditions, company
policies, rules, etc.
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Improving Individual Human Reliability in the Workplace
Appraisal Schemes
GLOSSARY
APPRAISAL SCHEME
A formal means of placing value on achievement or
effort, generally carried out on an annual basis. The
results may be used to determine the level of a pay
rise or a promotion.
Appraisal schemes usually involve the worker filling in a
self-appraisal form that is discussed at an interview with
their manager. A report is produced at the end of the
interview with a copy being provided to the worker and
to a senior manager, and a copy placed on the worker’s
personal file.
The self-appraisal form may request information about
what the worker feels they have accomplished in the
past year and their high and low points. It may also
ask what areas the worker is dissatisfied with and what
improvements they would like to see. The form may also
ask about the worker’s aspirations for the coming year.
In this way, the worker is given an opportunity to identify
what areas of their job they are satisfied with and what
areas they are dissatisfied with. They may also come up
with ideas to improve their job or to improve themselves,
e.g. additional training. This scheme gives the manager an
opportunity to discuss with the worker their thoughts on
the worker’s progress, and give praise and encouragement
where required.
Some appraisal schemes give the worker the opportunity
to comment on their manager. This needs to be
anonymous if there is a chance of reprisal.
Appraisal schemes are an excellent way of finding out
what problems exist within a workplace and, therefore,
give the opportunity for improvement. They also provide
a measure of the safety culture within an organisation.
More importantly, they allow the worker to comment on
their own progress and to voice their opinions. Workers
in appraisal schemes will often feel more motivated than
those not in such a scheme, particularly where hard work
and improvements are rewarded.
Appraisal schemes usually require the worker to complete an appraisal
form
SELECTION OF INDIVIDUALS
Matching Skills and Aptitudes
An employer may wish to select only those workers who
will conform to his or her safety standards – either existing
workers for new or different tasks or prospective workers.
This selection process is often by interview (at least in part)
and sometimes involves aptitude tests.
Be aware that selection in this way may not lead to large
improvements in reliability because people may behave
differently once they have the job.
Some of the best selection techniques involve
competency-based interviewing which identifies the
skills, talents and abilities required by the job and may
assess:
• Effectiveness of communication (verbal and written).
• Problem-solving ability.
• Ability to use technology.
• Whether they provide input or views on safety issues.
• Whether they follow safety instructions.
• Teamwork, etc.
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Improving Individual Human Reliability in the Workplace
Training and Competence Assessment
• On-the-Job Training
On-the-job training provides trainees with experience
which is a combination of work-based knowledge and
skills development. As the trainee gains experience,
the range and complexity of tasks that he/she can
undertake without detailed guidance increases. The
process of learning can be improved by:
–– Demonstration.
–– Coaching (carrying out tasks with guidance).
–– Projects.
The instructor assesses the competence of the trainee
as their skill level increases.
This training is effective, providing the trainee is shown
the correct way of carrying out the task; bad habits
can develop from the start if the trainee is placed with
someone who does not follow the correct procedures.
• Off-the-Job Training
Off-the-job training is carried out away from the work
environment in a number of ways:
–– Lectures - one-way communication in which all the
talking is done by the lecturer. It is a good way of
teaching a large number of students simultaneously.
The limitations are:
–– There is a very low rate of retention. Adequate
backup notes are essential.
–– Students may not understand the presentation
and be unable to seek clarification.
• Seminars - where discussion is encouraged and
students can learn from the instructor and from each
other. The number of students who can usefully take
part at one seminar is a limiting factor.
• Programmed instruction - provided through a
combination of distance learning or open learning
packs, computer or audio-visual programmes with no
direct involvement of an instructor. However many
distance learning packages do have access to tutors
for advice or assistance through e-mail or telephone
contact.
Fitness for Work and Health Surveillance
Some jobs, often called ‘safety critical’, involve activities
that require a person’s full, unimpaired control of their
physical and mental capabilities. For example, a tower
crane operator will need:
• To be able to climb safely up the mast to the cab.
• Good eye sight.
• To not suffer from any condition that might make him
or her prone to lose consciousness.
© RRC International
In such circumstances the employer would require a full
medical assessment of the prospective worker by an
occupational health practitioner. Although the results of
the assessment are confidential to the worker and the
practitioner, the employer can expect to be given a general
report specifying whether the prospective worker is:
• Fit for work.
• Fit for work with restrictions.
• Temporarily unable to meet the fitness standard.
• Unable to meet the fitness standard for work to carry
out specific jobs.
Health surveillance involves implementing systematic,
regular and appropriate procedures to detect early signs of
work-related ill health among workers exposed to certain
health risks and then taking appropriate action. Examples
include hearing tests, lung function tests and blood tests
for substances such as lead.
For most workers, employment health surveillance is not
necessary, but criteria to indicate where health surveillance
could be valuable include:
• Specific legal requirements.
• An identifiable disease or adverse health condition
related to the work concerned.
• Valid techniques available to detect indications of the
disease or condition.
• A reasonable likelihood that the disease or condition
may occur under the particular conditions of work.
• Surveillance likely to further the protection of the
health and safety of the workers to be covered.
Support for Ill Health and Stress
Providing support for workers suffering from ill health
(including stress) will be beneficial for both the worker
and the employer. A good occupational health service will
advise on a rehabilitation programme so that the worker
can readjust to the work environment and not jeopardise
their recovery. For example, an individual who has suffered
from a stress-induced illness, such as symptoms of anxiety
or depression (whether or not it has been caused or made
worse by the work) is likely to benefit from working parttime before returning to full duties.
REVISION QUESTION
7. Identify four different methods by which
employees can be motivated.
(Suggested Answer is at the end.)
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Organisational Factors
KEY INFORMATION
• Human error is increased by inadequacies in:
–– Policy.
–– Setting of standards.
–– Planning.
–– Information.
–– Responsibilities.
–– Monitoring.
• The safety culture of an organisation has a major influence on behaviour as does the development of small
groups and peer pressure.
• In any organisation there are both formal and informal structures.
• Communication mechanisms within an organisation vary in their complexity, reliability and formality.
• During periods of change, conflict may occur which needs to be resolved.
EFFECT OF WEAKNESSES IN THE SAFETY
MANAGEMENT SYSTEM ON THE
PROBABILITY OF HUMAN FAILURE
Information
Inadequacies in Policy
• Accurate,
Organisations must recognise that they need to consider
human factors as a distinct element which must be
recognised, assessed and managed effectively in order
to control risks. For this reason, human factors must be
considered and included in the company health and
safety policy; if they are not, then it is more likely that
these important factors that can affect the way in which
individuals work will be overlooked and human failure is
more likely to occur.
For example, some of the common organisational causes
of human failure include:
• Inefficient co-ordination of responsibilities.
• Poor management of health and safety.
Both of these stem back to inadequacies in policy. If
the health and safety policy defines the responsibilities
correctly and the ways in which health and safety are to be
managed, then failure is less likely to occur due to these
causes.
The availability of information within an organisation or
system is vital and the information should be:
• Timely (e.g. it is no good being informed of a new
procedure three weeks after the implementation date),
and
• Relevant.
Too much information can be overwhelming and will mean
that the important bits may get overlooked.
Providing the right information, at the right time, and
to the right people, is not easy, but it goes a long way
to ensuring a good working system and one where the
workers feel involved and appreciated. One example is
ensuring written instructions (including warning signs) are
clearly understood by everyone in an appropriate language.
Anyone who has worked for a company where information
was not provided adequately knows the confusion and
mistrust this can cause.
The information required may range from the structure of
the organisation and the responsibilities within it, to the
operating instructions for a piece of equipment.
Setting of Standards
The setting of standards and the use of benchmarking is
a feature of any safety management system. Recognising
human error is essential in such areas as identifying
foreseeable misuse is a necessary element of a suitable and
sufficient risk assessment.
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Organisational Factors
Planning
The proper planning of a system ensures that it works
effectively, and so all aspects of it must be taken into
account. This includes the inputs, the outputs, the work in
the middle (production/processing) as well as the effect of
the environment. All these areas need to be looked at to
see how they affect the system or how the system affects
them. Different scenarios should be considered so that the
system can operate in changing circumstances.
For efficient working, system planning must take account
of relationships between processes, i.e. the organisation
and communications, and the ability to adapt to change.
This might include:
• Proper work planning, including the task steps as
well as relationships with other tasks – to remove
unnecessary work pressure.
• Properly integrated procedures and safe systems of
work.
• Proper co-ordination.
• Communications – two-way to allow feedback for
improvements and clarification.
Responsibilities
To implement an effective system, everyone involved
must understand their role and how it integrates into the
system. Each person must also appreciate the effect on
the system as a whole if they don’t play their part. Unless
responsibilities are clearly defined and understood, there
will be an increased risk of tasks not being fulfilled, e.g.
maintenance. This will have a consequential effect on
safety and health.
Monitoring
Feedback and monitoring of a new system is vital to
ensure that the system works and that, where necessary,
improvements are made. Human error is significantly
reduced by providing proper, timely feedback to the
individual or group.
INFLUENCE OF SAFETY CULTURE ON
BEHAVIOUR AND EFFECT OF PEER GROUP
PRESSURES AND NORMS
The safety culture of an organisation has a profound
impact on the behaviour of those who work within it.
A poor safety culture will tolerate indifferent and even
dangerous behaviour, which will inevitably become the
norm so that even workers well aware of unsafe practices
will tolerate poor practices. One such influence is peer
pressure from work colleagues.
GLOSSARY
PEER
A person of the same level or rank.
Group Formation
In a social situation we group ourselves with those of a
similar outlook. In the work situation, we have little choice
as to who we work with. A lot of work situations involve
group work or committees and discussion groups. Social
groups are an essential part of life, since many activities
cannot be performed alone.
Group Reaction
In large groups, the majority scarcely speak at all; there
is often a wide variety of personalities and talent. There
are differences in behaviour and opinions, discussion is
restrained, and disagreement is easily expressed. The group
tends to create rules and arranges for division of labour.
Most people prefer to belong to a fairly small group. Each
individual can then exert influence on the group, and
speak when they wish to, and there is adequate variety
of personality to tackle common tasks, and for social
purposes.
Group Development
Groups develop ‘pecking orders’ in terms of the amount
of speech and influence permitted. Dominant individuals
struggle for status and an order develops, which might
not be the one that management would want. Low status
members talk little, speak politely to senior members, and
little notice is taken of what they have to say.
A person’s position in the group depends on his or her
usefulness. The system is maintained. A person who talks
too much is stopped. High status members are encouraged
to contribute. Group interaction depends on the person’s
status within the group. When away from the group, a
person reverts to his or her own individual personality. A
person can be dominant at work, and yet introverted when
away from the workplace.
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Organisational Factors
Group Control
A group will:
• Establish standards of acceptable behaviour or group
‘norms’.
• Detect deviations from this standard.
Nearly all organisations are hierarchical in structure, i.e.
they have different levels of authority and responsibility
within their structure.
The simplest way of depicting such a functional hierarchy
is with a line diagram (or organisation chart) similar to the
one that follows.
• Have power to demand conformity.
Attempts to modify the behaviour of an individual group
member who does not conform to group norms might
involve:
• The “cold shoulder”.
• Verbal hostility and criticism.
• Ridicule.
• Spreading unflattering gossip.
• Harassment.
• Disruption of work.
• Overt intimidation.
• Physical violence.
There are differences between the methods used by
groups of men and groups of women; groups may engage
in gender and racial discrimination, which is difficult for
management to control.
A lot of safety and health activity tends to be aimed at the
individual, when it is much better to target the group. If
the dominant leader of the group is very safety-conscious,
then safety can quickly become a group norm.
INFLUENCE OF FORMAL AND INFORMAL
GROUPS
Formal Groups
You will remember that we looked at formal and informal
organisations in an earlier element.
Formal organisations:
• Are established to achieve set goals, aims and
objectives.
• Have clearly defined rules, structures and channels of
communication.
• Are often divided into productive and nonproductive, productive organisations being involved in
the production of goods and services.
To be successful, an organisation has to have clearly
defined objectives and be positive in aiming to achieve
them in the most efficient manner. Where this positive
direction is lacking, an organisation is likely to fail.
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Organisational Factors
Managing Director
Executive
Director,
Marketing
Executive
Director,
Production
Executive
Director,
Finance
Human Resources
Manager
Executive
Director,
Human Resources
Training
Officer
Safety
Practitioner
Functional hierarchy
HUMAN
RESOURCES
FINANCE
SALES
SITE A
SITE B
SITE C
Matrix chart of organisational structure
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Organisational Factors
Organisations also make use of matrix charts to depict
organisational structure. In the figure below, staff functions
are shown across the top and line functions down the side.
(Can you remember the difference between staff and line
functions from an earlier element?) Interaction takes
place where the functions cross.
Concentric circle charts (see the following figure)
show the management functions to be the hub of
the organisation around which all other decisions and
functions revolve.
Concentric circle chart
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Organisational Factors
Informal Groups
The organisation chart shows the formal organisation
of the company and indicates the direction of
communications. There will also be formal working
groups and committees. In a large organisation this can
be cumbersome and some decision-making processes use
informal routes. The safety practitioner needs to be aware
of these informal methods.
Although a formal structure would suggest that he might
communicate with the works foreman by reporting to the
human resources manager, who contacts the managing
director, who then passes the information or instruction to
the foreman via the production manager and supervisor, in
practice the safety practitioner goes direct to the foreman
and, if necessary, reports this using the formal channels.
Within any organisation there is a ‘grapevine’. This is
usually very effective in passing on gossip and information.
Since the source is difficult to trace, the information
might not be totally reliable. So, superimposed on the
formal organisational structure is an informal structure of
communication links and functional working groups. These
cross all the barriers of management status and can be
based on:
• Family relationships.
• Out-of-work activities, such as the golf club, or the
local gym.
• Valuable experience or expertise.
ORGANISATIONAL COMMUNICATION
MECHANISMS AND THEIR IMPACT ON
HUMAN FAILURE PROBABILITY
Every organisation depends upon an intricate
communication network; the bigger the organisation,
the more elaborate the system. The precise form of
the network will vary from company to company. The
following networks and the direction of communication
they deal with are the most common, although in practice
the communication system in a particular company will
inevitably be far more complex. Communication systems
vary in their complexity, reliability and formality.
Modes of Communication
Communication can be either one-way or two-way.
In one-way communication:
• Sender identifies the message.
• Sender transmits the message.
• Receiver receives the message.
• Receiver interprets the message.
Although this is quick and gives the perception of
efficiency and control, there is no opportunity for feedback
and the assumption is that the receiver has paid adequate
attention.
Examples include: a tannoy message in a factory, a safety
poster, following written or e-mail instructions.
In two-way communication there is the opportunity for
the receiver to transmit information or questions back to
the original sender and for the sender to respond, such
that a conversation takes place. Although more complex
and time consuming, two-way communication is likely to
be more effective and reliable by placing the onus on both
parties rather than one. Achieving a mutual understanding
between the two parties ensures that the correct message
is received and understood, and contributes to an
improved safety culture.
Examples include: a one-to-one meeting, a tool box talk
with the opportunity for questions, etc., or a telephone
call.
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Organisational Factors
Shift Handover Communication
Shift working and shift handovers are characteristic of
many organisations, not only in the process industries,
but also in health care. During shift handover, relevant
information has to be communicated to maintain the
continuity of the activities; if this fails there is the risk of
serious consequences. A key factor in the Piper Alpha
disaster in 1988 (see earlier) was the failure in the permitto-work system, such that the oncoming shift members
were unaware of the removal of a safety valve. This failure
led to actions that initiated the disaster.
Board
Principal
Executive
The UK British Medical Association has published guidance
on good practice handovers in healthcare, and detailed five
questions:
Departmental
Managers
• Who should be involved? – All key personnel at all
grades.
• When should handover take place? – At fixed times,
of sufficient length and arranged to allow both the
off-going and on-going shifts to attend within their
working hours.
Middle Managers
• Where should it take place? – Close to the most used
work sites so that there is room for both sets of staff to
attend.
• How should handover happen? – a specific formal
format should be devised and consistently followed.
Supervisors
• What should be handed over? – this might include
written notes as well as electronic information.
Organisational Communication Routes
Vertical Communication
First-Line Supervisors
The amount of communication downwards tends to
exceed that going upwards.
• Downwards
Communication will usually be made along the lines
of authority, from managing director down to section
leader and on to the clerk and shop-floor worker (see
following figure).
Employees
Vertical communication – downward and upwards
At each managerial level there must be responsibility
for passing on information. Each superior level must
be responsible for ensuring full, accurate knowledge
and understanding at the next subordinate level. The
importance and use of communication must, therefore, be
included in any management training programme.
The passing ‘downwards’ of some directive,
communication or instruction, implies temporary ‘storage’
of that information in the mind, or the “in-tray”, of
all intermediate handlers. Careful consideration must
be given, therefore, to the most appropriate type of
information storage and display system.
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Organisational Factors
Some senior staff believe that the only effective way to
pass information is by word of mouth – their mouth! They
think they are the only really effective communicators
in the organisation, but this can mean that they find
themselves with no time to make decisions because all
their time is taken up ensuring that the decisions they have
made have been passed on to ‘all concerned’.
Office
Manager
Invoicing
Supervisor
Wages
Supervisor
Costing
Supervisor
Ledger
Supervisor
Services
Supervisor
Costing
Senior Clerk
Estimating
Senior Clerk
Stock Control
Senior Clerk
Bought Invoices
Senior Clerk
Clerks
Clerks
Clerks
Clerks
Vertical communication within a department
• Upwards
Communication upwards is equally important in any
organisation - ideas, suggestions for improvements,
and opinions on existing systems, communications
and techniques are all important for management to
consider and use.
Although the amount of downwards communication
is usually greater than that going up, managers should
encourage an increase in the flow upwards, although
much depends on the time the manager has available
to deal with the upwards communications.
Office and shop-floor workers are in direct contact
with the actual work carried out and can often see
ways to improve processes and production. The regular
flow of such ideas has been of considerable value to
organisations in reducing costs, cutting production
times, introducing improved layouts, and in creating
an atmosphere of co-operation and goodwill between
workers and management.
Research has shown that it is in the upward flow of
information that the greatest shortcomings exist,
especially in recent years with the use of management
information systems, and the selection and processing
of the ‘vital’ information managers need to have.
Whereas downwards communications are usually
‘directives’, i.e. they initiate action by subordinates,
upward ones are usually ‘non-directive’, i.e. they report
results or give information, but are not necessarily
intended to prompt action.
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Organisational Factors
Horizontal Communication
Information is also channelled horizontally, both within a
department and between departments.
We give information to and receive it from colleagues
in our own department and we have contacts
with our opposite numbers in other departments.
These communications are of the greatest value in
administration, particularly in effecting co-ordination (see
the following figure).
Remember that information flow is subject to variation in
speed and quantity; activity will vary according to the time
of day, the day of the week, and the month or quarter.
The characteristic of feedback is vital in effective
communications. It should inform the sender of
information that his or her message has been understood
and acted upon, hopefully in the expected manner,
bringing about the planned objective.
Internal communications - horizontal
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Organisational Factors
Inward and Outward Communication
• Inward
Here we see the effect of all the personal face-to-face
calls on people at all levels in the organisation: the
incoming telephone calls and e-mails from people of
all kinds making contact with various members of staff,
and postal correspondence arriving daily.
• Outward
The amount of communication outwards from any
organisation is sometimes grossly miscalculated.
Outgoing communications are both formal and
informal, both explicit and implicit.
In this same category we can include the behaviour
of responsible members of staff when they are off
company premises; their behaviour and expressed
attitudes may be seen as reflecting those of their
organisation.
Outward communications also include the various
kinds of advertising and promotional devices the
organisation uses.
PROCEDURES FOR RESOLVING CONFLICT
AND INTRODUCING CHANGE
The introduction of change may be accompanied by
conflict within an organisation; it is vital that conflicts
are resolved to ensure a good working environment and
atmosphere.
GLOSSARY
While tackling the above areas will help to resolve conflict,
note that there are two broad approaches to conflict:
• Unitary Approach
This involves the idea of the common aims of the
organisation, i.e. its well-being and how workers and
management have the same basic interest in that wellbeing. According to this view, conflicts arise because
workers do not fully appreciate where their true
interests lie. There is also some blame on management
when conflict occurs, because management must have
failed to communicate with workers and convince them
that their best interests lie in co-operation and not
conflict. According to the unitary approach, the best
way to tackle conflict at its roots is to generate team
spirit, company loyalty, and good working conditions.
• Pluralist Approach
This recognises that the organisation is made up of
various groups whose interests and goals may differ.
Conflicting parties will benefit from identifying issues
of compatibility.
Conflict should be controlled by balancing the various
groups. Where strong management works alongside
strong trade unions, each side respects the other
and does not lightly enter into conflict. The causes
of conflict are brought out into the open and hard
bargaining takes place, but serious disruption to the
work of the organisation is avoided.
Generally managers take the unitary approach to conflict
and change, while trade unions favour the pluralist
approach.
ORGANISATIONAL CONFLICT
Can be defined as: “any perceived clash of interests
between individuals, groups or levels of authority in
an organisation”.
During periods of change, conflict can occur because of:
• Personality clashes: change bringing people of
differing personalities into new relationships.
• Poor communication: can lead to misunderstandings
and confusion which can fuel conflict.
• Conflicting interests: change can alter the power
relationships within an organisation.
• Lack of leadership and control: resulting in a lack of
clear direction which can lead to conflict as different
people interpret the scenario for change in different
ways.
REVISION QUESTIONS
8. Outline the differences between formal and
informal groups within an organisation.
9. Explain how peer group pressure can influence
behaviour at work.
(Suggested Answers are at the end.)
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Job Factors
KEY INFORMATION
• Job factors have a major influence on human error, including:
–– Task complexity.
–– Patterns of employment, e.g. short-term contracts.
–– Payment systems, e.g. piece work.
–– Shift work.
• Task analysis breaks down the job into individual steps, which can be further analysed.
• Ergonomics is the study of adapting the job to the individual.
• Poorly designed workstations can increase human error as well as cause ill health.
• Physical stressors, e.g. extremes of temperature, fatigue and stress, all have an adverse effect on human reliability.
Job factors include such things as:
• The equipment, e.g. design and maintenance of
displays, controls, etc.
• The task itself, e.g. complexity.
• Workload.
• Procedures or instructions – clarity, completeness.
• Disturbances and interruptions.
• Working conditions – noise, temperature.
EFFECT OF JOB FACTORS ON THE
PROBABILITY OF HUMAN ERROR
Task Complexity
The complexity of the task can have a significant effect on
the propensity for human error. Those tasks which involve
complex calculations, decisions or diagnoses will present
more opportunity for such error. Such tasks should be
broken down into simpler units to give greater clarity.
Patterns of Employment
These days it is accepted practice for workers to be on
short-term contracts and this clearly has an effect on
individuals seeking job security. Some people in this
position may suffer from stress due to the lack of job
security, particularly if they have always had a ‘permanent’
job in the past. Other people acknowledge that there are
now few ‘jobs for life’, and take short-term contracts in
their stride.
‘Permanent’ contracts may lead to complacency in the
workforce, in which case the employer needs to ensure
that individuals achieve their potential and work towards
the company goals. There are many ways of encouraging
improved performance, e.g. reward and incentive schemes.
The way the work is organised between people can also
have a major effect on performance. People working in
small teams with some variety to their tasks can help build
comradeship and a good working environment. However,
where people work alone, work can become a lonely place,
and the tasks can become monotonous.
Payment Systems
The way in which people are paid can have an effect on the
way they work. For example, piecemeal workers are paid by
performance; abattoir workers are often paid per animal
slaughtered, so for them speed is important, because the
faster they work the more they get paid. While safety may
not be the top priority, they understand that their own
safety is paramount because if they injure themselves, they
won’t be able to work and then they won’t get paid. So,
by default, personal preservation may lead them to work
more safely.
This is really the same for all self-employed people. On the
other hand, employed people who still get paid if they are
absent from work may not think about their own safety in
these terms, and so may or may not work more safely.
Short-term contracts often mean that the employer can
choose to retain the best workers. Where there is a good
safety culture in place, this will often mean workers who
perform well and safely. Where the safety culture is poor,
this may mean workers who work the quickest will be kept
on. So, the type of organisation will determine how the
individual will work in order to ensure that their contract is
renewed. On the other hand, where short-term contracts
are in place there may be little loyalty from the workforce
and so turnover of staff (particularly good performers)
may be high.
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Job Factors
Shift Work
Shift work has a great effect on an individual’s
performance. In addition to fatigue and stress, individuals
may find that their social lives and family life are affected.
The effects of this will rather depend on the individual and
their circumstances, as well as the shift pattern itself. If,
however, an individual is unhappy at home, then this will
often spill over into their work life and performance may
be affected.
Shift workers (especially night workers) may experience
negative effects on their health:
• Gastrointestinal problems are more likely to occur due
to eating snack meals during work hours.
• Respiratory problems such as asthma tend to be worse
at night, as do allergic reactions.
• Lung function also declines at night, especially for those
people with chronic respiratory problems.
Clearly where people’s health is affected, performance may
also be affected.
Shift work interferes with the body’s natural circadian
rhythm (the internal body clock which dictates when the
body should be active and when it should rest). Even when
working nights, the body still reduces body temperature
in the early hours of the morning, reduces blood pressure
and stops digestion, which leads to an individual feeling
sleepy and less alert.
Shift workers need adequate rest between shifts, as well
as regular rest days to “recharge their batteries”. The shift
pattern itself may also affect individuals. Shift patterns that
alter once a week are likely to be more difficult to adjust
to, rather than those that change more rapidly or more
slowly.
APPLICATION OF TASK ANALYSIS
Task analysis is a process that identifies and examines tasks
performed by humans as they interact with systems. It is
a means of breaking down a task into each individual step
and is a technique that looks at an activity in detail. The
activity in question may be one where a number of people
have injured themselves. By breaking the task down into
each step, the cause of the injury may become apparent,
and a better way of completing the task may be identified.
© RRC International
For example, consider the school cooks who produce
hundreds of hot meals per day. A number of incidents
have occurred, which on the surface seem unrelated, e.g.
back strain, burns, slips and trips. Looking more closely,
however, it seems that all the accidents have occurred
while removing or putting items in the oven. After
breaking down each step, it becomes apparent that the
oven door does not always stay fully open so the cook has
to balance the trays of hot food while trying to keep the
door open. This sometimes means holding the food in an
awkward manner (leading to back strain) or spilling the
food (leading to slips and trips) or being burnt by the oven
door. In this simple example, it may be possible just to fix
the door so it stays open, or to change the procedures, or
it may mean someone has to hold the door open while
another person removes/replaces the food.
By breaking down a task, you can see exactly what happens
without making assumptions about some of the steps.
ROLE OF ERGONOMICS IN JOB DESIGN
Ergonomics is concerned with “fitting the job to the man”,
rather than expecting the individual worker to adapt to the
job.
Influence of Process and Equipment
Design on Human Reliability
Human beings are unreliable – how unreliable depends
on the individual and the work environment. Consider the
effect that being in a very hot environment has on your
work performance; or, when you have had a large lunch,
how your output is affected by a feeling of sleepiness.
However, much can be done to minimise such effects by
improving the environment and making the task such that
errors are minimised. This is achieved by careful design of
any controls.
Man and machine are each better at some things than
the other. Ideally, you want to use the strengths of both
to minimise possible weaknesses; together they represent
the ‘system’ for meeting the requirements. This can be
illustrated diagrammatically as in the following figure.
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Job Factors
Statement of objectives
Separation of functions
Allocation of functions
(Human)
Development of
personnel
Human-machine interface
design
(Hardware)
Development of
equipment
System integration
System design process
Ultimately, every piece of plant can be represented by
what is often called the MMI, or ‘man-machine interface’.
Ergonomics is the study and design of this interface, such
that the operator can perform his or her duties efficiently,
in comfort and with minimum error.
Grouping of displays and dials next to their controls, and
consistency in these displays – for example, all moving
the same way for increase – are important in allowing
the operator to form a mental picture of what is actually
happening in the plant under that person’s control.
• Displays should be arranged so they can be scanned
with minimum effort.
• Display dials should be the appropriate type for the
reading (digital v. analogue).
Consistency is important in the action of control devices;
we expect to turn something on and increase some
variable, by turning a knob clockwise. Relative positioning
of control devices and displays is important. People expect
to see a reaction to an action, even if it is only a light that
indicates the action is being acted upon (the lift call-button
effect) and, of course, controls should be within easy reach
of the operator. Controls should be organised and laid
out so as to logically follow the process. They should be
clearly marked or labelled. The number of controls should
generally be kept to a minimum.
Emergency arrangements should be distinctive so that
emergency stop controls can be easily located, and
any audible warnings should take account of expected
background noise levels.
• Dials should have identified areas for normal and
abnormal readings to make it easier to see if something
is starting to wander, e.g. a fuel gauge in a car.
• Bulbs and other indicators should be shielded from
glare so that their status cannot be confused.
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Job Factors
Possibly the most important aspect is the worker’s
immediate working space and environment. Reliable work
cannot reasonably be expected from an operator who has
a headache or a sore back within an hour of starting work.
Factors such as noise, dust, smell, vibration, temperature
(and temperature changes), lighting levels (and glare), and
humidity all contribute to a worker’s ability to concentrate.
Psychological factors such as the degree of concentration
necessary, and the ability to mentally rest and ‘coast’ for
a short period, are also important; also remember the
importance of providing chairs, if appropriate, to avoid
fatigue from prolonged standing.
The Worker and the Workstation as a
System
The layout of controls, displays and seating for
convenience of operation are often overlooked.
Fumes/Gases
In ergonomics, the man, the machine, and the working
environment may be considered as the elements that
together comprise a system.
When considering the ergonomic ‘fit’ of the workplace
to the worker, there are a number of factors to take into
account.
ENVIRONMENT
Heat/Cold Glare/Darkness Vibration Noise
To ensure that the strengths of man and machine are
utilised, a Fitts List (named after Paul Fitts, who developed
the technique) is produced for the system.
MAN
Example of Fitts List
Activity
Machine
Human
Speed
Much superior
Lag > 1 second
Power
Consistent,
large, constant,
standard and
precise forces
2 hp for 10 seconds
High
Not reliable, must be
monitored
Consistency
0.6 hp for minutes
0.2 hp over day
Reasoning
Good deductive
Good intuitive
Input
sensitivity
Some outside
human range
(e.g. X-rays)
Wide range, good
pattern identification
MACHINE
Display
Bells
Switches
Dials
Buzzers
Knobs
Counters
Hooters
Levers
Gauges
Lights
Pedals
Ergonomic ‘Fit’
Note that this is given as an example for a system that
requires the given ability. Each system will require a Fitts
List developed to suit its specific requirements for actions
to be performed, although with practice, such a list does
not take long to produce.
Elementary Physiology and
Anthropometry
The skills of an ergonomist include:
• Anthropometry
This is a study of human measurements, such as shape,
size, and range of joint movements. A machine must
be designed for the person. Since no two people are
the same, a design is required which will suit, or can
be adapted for, a wide range of sizes of individuals. It is
typical to design for a range of two standard deviations
from the mean. (Remember that we looked at the
statistical terms “standard deviation” and “mean” in
an earlier element.) This includes all but the extreme
10% at each end of the measurement scale. Group
characteristics must also be considered, for example,
the average height of people varies between different
populations.
The appropriate grouping and display of controls is vital
© RRC International
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Job Factors
• Physiology
This is a study of the calorific requirements of work
(how much energy is needed) and body functions,
the reception of stimuli, processing and response.
The operator and machine must be complementary.
A person must not be expected to do more than the
human body is capable of. Some things are best done
by a person; other things by a machine.
Physiology includes a study of the operation of
machines. A person can operate two foot controls
when sitting, but only one when standing. An
investigation by Cranfield Institute of Technology
determined the ideal dimensions of the average
operator of a horizontal lathe - ‘Cranfield man’ would
need to be 1.35 m tall and have a 2.44 m arm span.
The ergonomist should make a contribution at the design
stage to try to prevent problems occurring later.
Degradation of Human Performance
Resulting from Poorly Designed
Workstations
Many regions of the world produce design standards.
The British Standard 3044:1990, Guide to Ergonomics
Principles in the Design and Selection of Office Furniture,
is one example of the help available to designers in the
UK. Though UK-based, the HSE leaflet INDG90(rev3)
Ergonomics and human factors at work – A brief guide
aims to help employers and managers to understand
ergonomics and human factors in the workplace by giving
examples of ergonomics problems and simple, effective
advice about how to solve them.
ERGONOMICALLY-DESIGNED CONTROL
SYSTEMS
• Production Process Control Panels
The operator of a production process control panel
must be able to operate the panel from a safe place.
For some production processes, this may be from an
adjacent area or for more dangerous operations the
panel will be located at a safe distance, or even within
an enclosed area away from the production area. Noise,
dust and fumes must all be considered.
The operator must be able to reach all the dials,
switches, etc. easily. Emergency controls must be clearly
identifiable and easy to operate. The operator must
also have a view of the production area so that they can
see what is happening and react, as necessary.
• Crane Cab Controls
A crane driver has to be in absolute control of the load
that is being moved, because the slightest slip of the
controls may result in damage to buildings, materials or
people. For this reason it is vital that the controls in the
cab are within easy reach and move in straight lines to
permit ease and delicacy of control. The driver must be
provided with an adjustable seat (to fit accurately 90%
of all possible sizes) so that he/she has a full view of
the working area.
The driver must also be protected from the ingress of
dust, fumes and heat from the external environment.
The provision of filtered and refrigerated air, where
necessary, ensures cool and comfortable working
conditions.
Workstations are usually designed for the ‘average’ person.
If a doorway was designed just for the average person,
then some of the population would have problems getting
through.
Workstations need to be capable of adjustment.
Unsuitable workbench height causes the operator to
develop musculoskeletal problems.
• If the workbench is too high, the operator has to adopt
an unnatural posture, with the elbows away from the
body and the shoulders raised. This causes discomfort
in the shoulders and neck.
• If the work surface is too low the operator will have
to lean forward. This causes neck and lower back
problems.
• Repetitive movements, particularly those requiring
the operator to exert force or use an unnatural action,
can lead to upper limb disorders. One problem is
tenosynovitis, or inflammation of the tendons of
the hand and wrist. This is a common problem with
keyboard operators.
A crane driver must have a full view of the working area
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Job Factors
• Aircraft Cockpit
It is vital that a pilot can interface easily with all the
controls in the cockpit. The controls/displays must
be fitted around the cockpit in a logical way so that
the pilot can easily reach/see the more important
controls/displays, e.g. speed and altitude dials, while
he/she may need to move to reach the less important
ones. It is important that safety-critical switches cannot
be inadvertently operated. These should be designed
so that there has to be a positive action by the operator
in order to initiate them.
Emergency controls must be clearly identifiable,
easy to use and situated in a suitable location. The
emergency controls must be accessed quickly to
prevent unnecessary delay in stopping the activity that
they control.
It is also important that the pilot can adjust his/her
position to obtain the best field of vision and enable
quick responses for movement of the various controls.
For this reason, the pilot must be able to alter the
height and position of his/her seat to ensure that the
controls are in comfortable reach. The temperature,
ventilation and lighting in the cockpit must also be
adequate, and these must be adjustable to suit the
individual.
• CNC Lathe
The CNC lathe is computer-operated using a key
pad or keyboard. It is important, therefore, to ensure
that the operator can access the key pad or keyboard
easily, and that they can use the keys comfortably. For
this reason, the operator must be able to adjust their
operating position, i.e. chair height and position, as well
as the actual position of the keyboard.
MORE…
You can find further information on the importance
of design on human factors at:
www.hse.gov.uk/humanfactors/topics/design.htm
© RRC International
RELATIONSHIP BETWEEN PHYSICAL
STRESSORS AND HUMAN RELIABILITY
GLOSSARY
STRESS
The reaction people have to excessive pressure or
other types of demands placed on them.
Stress can be caused by a number of factors including
physical stressors, such as extremes of heat, humidity,
noise, vibration, poor lighting, restricted workspace, etc.
The presence of physical stressors has a negative effect on
people and means that errors are more likely to occur.
Physical stressors affect how comfortable a person is and
their ability to concentrate, and may even make them
feel unwell. Different people may be affected by varying
degrees of the physical stressor.
For example, some people are not affected by
increased room temperature, while others start to feel
uncomfortable and may become restless after a few
degrees’ rise. Pregnant women are more likely to be
affected before other members of the workforce. However,
if the temperature continued to rise, then more and more
people would be affected and the likelihood of errors
occurring would rise too as concentration levels dropped.
In addition to this, people are more likely to lose their
tempers or have decreased levels of patience, which again
may lead to errors or incidents occurring. Eventually a very
warm working environment may result in fainting or heat
exhaustion, which could have serious implications in a
high-risk environment.
Some environments are very warm by their nature, e.g.
working in a busy kitchen. Procedures should be in place to
ensure that individuals are protected from excessive heat,
e.g. regular rest breaks away from the heat, availability of
cold drinks, good air circulation, etc.
In order to prevent errors, or reduce them as far as
possible, you need to ensure that the working environment
is as comfortable as possible. Where physical stressors are
likely to be a problem, e.g. in a noisy environment, other
controls must be in place to prevent them affecting an
individual’s ability to work safely. These controls may be
in the form of suitable personal protective equipment,
limited time within the environment, or regular breaks, for
example.
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Job Factors
EFFECTS OF FATIGUE AND STRESS ON
HUMAN RELIABILITY
As we have said, stress is the reaction that people have
to excessive pressure and occurs when they worry that
they can’t cope. Stress can affect performance and an
individual’s ability to make decisions and work effectively.
Fatigue can be defined as ‘weariness after exertion’, or can
occur after repeated periods of stress. Severe fatigue can
lead to poorer performance on tasks requiring attention,
decision-making, or high levels of skill. Shift work, working
at night, or extended hours can all result in fatigue and
have an adverse effect upon health. For safety-critical work,
such as train driving, the effects of fatigue can give rise to
increased risks.
Shift work, especially night working, can impact on safety.
During the night, job performance may be poor and tasks
completed more slowly. The hours between 02.00 and
05.00 are the highest risk for fatigue-related conditions.
Sleep loss can lead to lowered levels of alertness. Sleep
debt, which is a build-up of sleep loss, leads to reduced
levels of productivity and attention. These effects can also
affect early morning shift workers and people who are on
call.
MORE…
You can find further information on the effects of
fatigue on human performance at:
www.hse.gov.uk/humanfactors/topics/fatigue.htm
REVISION QUESTIONS
10. What effects might shift work have on an
individual’s performance?
11. How might the system of payment or terms
of employment at work affect an individual’s
performance?
12. Explain the term ‘ergonomics’ and discuss how
the poor application of ergonomics might lead
to injury and occupational ill health.
13. What features are present in an ergonomicallydesigned crane cab control system?
(Suggested Answers are at the end.)
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Behavioural Change Programmes
KEY INFORMATION
• Behavioural change programmes aim to change individual behaviour by positively reinforcing desired behaviour
and deterring undesired behaviour.
• They rely on:
–– Observations by supervisors and other workers.
–– Providing prompt feedback to improve behaviour.
PRINCIPLES OF BEHAVIOURAL CHANGE
PROGRAMMES
Such a change programme is best illustrated with an
example – speeding in a car.
Behavioural programmes aim to change individual
behaviour using certain techniques including:
What are the triggers that may cause somebody to speed?
• Observations.
• Late for an appointment.
• Feedback.
• Emergency.
• Goal setting.
• Road rage.
• Team working.
• Listening to exhilarating music.
The key principle is to positively reinforce the desired
behaviour and deter, or even punish the undesired
behaviour.
• Empty road.
These could be:
The first step is to identify the desired behaviour. The
behaviour should be specific, observable and easily
measured. In fact, simply observing behaviour can in itself
lead to a positive improvement in the behaviour, but this
will only be a temporary effect.
Now what about the consequences? These can be either
rewards or punishments:
• Arrive early/on time – Reward.
• Feel good – Reward.
• Have an accident – Punishment.
• Stopped by police – Punishment.
TOPIC FOCUS
• Increased wear and tear – Punishment.
Steps of a behavioural change programme:
A consequence will have a much greater impact if it:
Step 1: Identify the specific observable behaviour
that needs changing, e.g. increased wearing of
hearing protectors in a high noise environment.
• Happens sooner rather than later after the behaviour.
Step 2: Measure the level of the desired behaviour
by observation.
Step 3: Identify the cues (or triggers) that cause the
behaviour and the consequences (or pay offs) (good
and bad) that may result from the behaviour.
Step 4: Train workers to observe and record the
safety critical behaviour.
Step 5: Praise/reward safe behaviour and challenge
unsafe behaviour.
Step 6: Feedback safe/unsafe behaviour levels
regularly to workforce.
© RRC International
• Is certain to happen rather than unlikely.
• Is important to the individual.
So, with our driving example, if every time we exceeded
the speed limit we were immediately fined, motorists
would soon adhere to the required limits.
It is important to focus on the safe/unsafe behaviours and
not the desired outcome of the programme. So, if the
objective of such a programme is to reduce the incident/
accident rate, it should focus on safe behaviours (and
reward those) and not on the injury rate. If we rewarded a
low injury rate then this would encourage under reporting
rather than safe behaviours.
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Behavioural Change Programmes
Many behavioural change programmes identify a few key
behaviours that have, perhaps, led to accidents previously,
or gave cause for concern – for example, the failure to
wear gloves when handling knives, or to wear a seatbelt
while on a forklift truck. The desired behaviours are then
identified (such as “when driving the forklift truck the
operator wears his seatbelt”) and the observers then
observe against this specific behaviour. If the operator
is wearing his seatbelt, then positive reinforcement and
thanks are given. If the operator is not wearing his seatbelt,
then the observer highlights their concern and discusses
any barriers to safety that could have resulted in the action.
By being observed and given feedback regularly, workers’
behaviour changes, such that the correct behaviours
become almost good habits. At this point, a new behaviour
may be added to the observation sheet, and the process
continues.
ORGANISATIONAL CONDITIONS NEEDED
FOR SUCCESS IN BEHAVIOURAL CHANGE
PROGRAMMES
Behavioural programmes should not be viewed as quick
fixes and unless they are properly resourced with overt
continuing management commitment they are unlikely to
succeed.
As the behavioural-change process hinges on the ability
to give and receive positive and negative feedback, the
organisation and its employees must be ready to accept
this step. It may seem strange to have someone thanking
you for wearing PPE, but this positive feedback is a critical
part of the process. Equally, any negative feedback is there
for guidance and so should also be received with an open
mind, which can be a struggle if the safety culture is not
well developed.
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(accident frequency)
Safety performance
Behavioural Change Programmes
Technological and physical
condition approaches
Work systems and
procedures
People centred and
cultural approaches
Time
Actioning behavioural change
This graph illustrates that typically organisations first
consider the technical issues that affect safety, such as
having safe equipment and premises. When these are
in place they then turn to ensuring that the systems of
work and procedures are satisfactory. Unless these two
approaches are in place, a behavioural programme is
unlikely to work.
A behavioural programme is more likely to be effective if
the reward/punishment is:
• Likely or even certain.
• Important to the individual.
EXAMPLE OF TYPICAL BEHAVIOURAL
CHANGE PROGRAMME CONTENTS
All programmes need behaviour which can be easily
observed and assessed.
In a factory a process involves loading a pallet with 25kg
sacks of cement and then transporting the pallet to a lorry
for dispatch.
A checklist is then developed to identify the expected
behaviour and record the number of safe and unsafe acts.
Here is an extract:
• Given soon after the safe/unsafe act.
Feedback needs to be provided very soon after the safe/
unsafe act so that the safe behaviour is reinforced, not only
to the individual, but to all those affected, so that they
appreciate the impact of the programme, e.g. collective
results published weekly.
In one published study, workers were provided with
earplugs to protect them from very high noise levels.
The initial usage rate was only 35%. After a two month
programme in which the wearing of the plugs was
rewarded with tokens, the usage rate had increased to
90%. The scheme was finished and it was found that usage
had been maintained a further three months later. The
initial discomfort often experienced by wearers of hearing
protection had worn off and when users removed the ear
plugs their heightened awareness of the high noise levels
further reinforced the desired behaviour.
© RRC International
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Behavioural Change Programmes
Task
Expected behaviour
Loading pallet
Transporting
pallet by FLT
Safe
Unsafe
• Loader wears safety gloves
3
1
• Loader wears safety shoes
3
2
• Loader adopts safe lifting procedure
2
0
• Loader keeps environment tidy
1
1
• Loader deals with spillages
0
0
• Driver sounds horn when approaching exit doors
4
1
• Driver keeps within speed limit
4
2
• Driver keeps forks lowered
2
0
• Driver is courteous
2
0
21
7
Total
% safe
Not
seen
Comment
1
75%
For each of the two tasks a list of expected observable
behaviours is identified. Observers then regularly visit the
workplace and observe the behaviour and record whether
it was safe or unsafe or not seen. Observers may include all
workers and should not be just those with management or
supervisory roles.
Following each observation the feedback is given soon
afterwards, either individually or as a team, in which safe
behaviours are praised and unsafe behaviours discussed.
The worker(s) observed are invited to give feedback and
to explain, for example, why it was not feasible to wear
gloves. The discussion may lead to suggestions as to how
to change the task to improve safety.
Clearly the discussion will need to be handled carefully and
should not create hostility.
Following a series of observations, the percentage of
unsafe behaviour can be calculated and publicised:
Percentage safe behaviour =
Sum of safe observations
Sum of safe + sum of unsafe behaviours
× 100
REVISION QUESTION
14. Outline the steps of a behavioural change
programme.
(Suggested Answer is at the end.)
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Summary
SUMMARY
Human Psychology, Sociology and Behaviour
Factors that influence human behaviour include:
• Personality - how extrovert or introvert a person is.
• Attitude - their beliefs about safety.
• Aptitude – ability.
• Motivation - what inspires them to work safely.
There are a number of theories of human motivation:
• F. W. Taylor
He summarised scientific management as:
–– Design efficient methods for doing work, based on a scientific approach, such as subdivision of labour.
–– Set productivity goals.
–– Give financial rewards for meeting the goals.
–– Train the workers to use the methods.
• Mayo (Hawthorne Experiments)
The simple fact that workers were the subject of experimental study improved their performance.
• Maslow (Hierarchy of Needs) suggested five levels of need: Biological, Safety or Security, Social, Esteem and
Self-Actualisation.
• McClelland identified three human needs – affiliation, power, and the need to achieve.
• Herzberg identified two sets of needs in workers - hygiene factors (e.g. safe working conditions) and motivators
(e.g. recognition and reward).
• McGregor developed two theories:
–– Theory X – people are motivated primarily by money and are reluctant to take on responsibility.
–– Theory Y – people perform best with minimal supervision and control.
Experience, social background and education/training affect behaviour at work.
Rasmussen’s Model of knowledge-, rule- and skill-based behaviour states that:
• Skill-based behaviour describes a situation where a person is carrying out an operation without the need for any
conscious thought.
• Rule-based behaviour is at the next level - a situation where the operator has rules which he can apply to deal
with a specific situation.
• Knowledge-based behaviour is for situations where there are no tried rules or routines or the necessary skills.
Trial and error may be the only method available.
Perception of Risk
In relation to human sensory receptors:
• Each of our senses works in the same way by sending signals to the brain.
• We tend to screen out things we are not interested in.
• Sensory defects increase with age and ill health.
When perceiving danger:
• Perceptual set is dangerous because we assume both the danger and the solution without seeing the real issues.
• Our perception of hazards can be distorted.
• Errors of perception can be caused by physical factors such as fatigue and stress.
© RRC International
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Summary
• An individual’s perception of a situation is based on two sources of data:
–– Information from the senses.
–– Expected information.
The Hale and Hale model of accident causation includes the idea of perception. Developed from this was the Hale
and Glendon model of behaviour in the face of danger.
Human Failure Classification
HSG48 identifies two types of human failure: errors (accidental) and violations (deliberate).
Errors are actions or decisions which were not intended, involved a deviation from an accepted standard, and which
led to an undesirable outcome.
Errors can be characterised as: slips, lapses and mistakes.
There are three types of violation: routine, situational and exceptional.
In many major disasters, human error has been shown as a major contributory factor.
Improving Individual Human Reliability in the Workplace
Motivation may be improved by:
• Workplace incentive schemes.
• Reward schemes.
• Job satisfaction.
• Appraisal schemes.
• Selection of individuals by:
––
––
––
––
Matching skills and aptitudes.
Training and competence assessment.
Fitness for work schemes and health surveillance if appropriate.
Support for ill health and stress-related illness.
Organisational Factors
Weaknesses in the safety management system increase the probability of human failure. These include failures in:
• Policy.
• Planning.
• Setting of standards.
• Information.
• Responsibilities.
• Monitoring.
The safety culture of an organisation influences the behaviour of its individual members. One way is by peer group
pressures.
Groups, both formal and informal, within an organisation affect the control of risks.
Communication mechanisms within an organisation vary in their complexity, reliability and formality.
Communication between and within groups is important. It can be:
• Horizontal or vertical.
• Inward and outward.
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Summary
During periods of change, conflict can occur because of:
• Personality clashes: change often brings people of differing personalities into new relationships.
• Poor communications: can result in misunderstandings and confusion which can fuel conflict.
• Conflicting interests: change can alter the power relationships within an organisation.
• Lack of leadership and control: can result in a lack of clear direction, leading to conflict as different people
interpret the scenario for change in different ways.
Job Factors
The way in which work is organised for individuals with respect to shift patterns, means of payment and patterns
of employment can have an important effect on the way they carry out their job.
Task analysis is a process that identifies and examines tasks performed by humans as they interact with systems. By
breaking the task down into each step, the cause of an injury may become apparent, and the analysis may identify a
better way of completing the task.
The design of the work environment can have an effect on human reliability. The following are some issues to
consider:
• Displays should be arranged so they can be scanned with minimum effort.
• Consistency is important in the action of control devices.
• Factors such as noise, dust, smell, vibration, temperature, lighting levels and humidity all contribute to a worker’s
ability to concentrate.
The ergonomist’s skills include:
• Anthropometry - a study of human measurements, such as shape, size, and range of joint movements.
• Physiology - a study of the calorific requirements of work (how much energy is needed) and body functions, the
reception of stimuli, processing and response.
Human performance can deteriorate due to poor design of workstations, such as those that are too low, or too high.
Work that involves repetitive movements can lead to upper limb disorders.
Physical stressors affect how comfortable a person is and their ability to concentrate, and may even make them feel
unwell. These include: extremes of heat, humidity, noise, vibration, poor lighting, restricted workspace, etc.
Fatigue can be defined as “weariness after exertion” or can occur after repeated periods of stress. Severe fatigue can
lead to poorer performance on tasks requiring attention, decision-making, or high levels of skill.
Behavioural Change Programmes
Behavioural change programmes endeavour to change individual worker behaviour by positively reinforcing desired
behaviour and deterring undesired behaviour.
• Specific observable behaviour to be changed is identified and then measured.
• The cues that encourage the behaviour and resulting consequences are identified.
• Safe behaviour is encouraged/rewarded.
• Unsafe behaviour is challenged.
Such programmes rely on:
• Observations by supervisors and other workers.
• Providing prompt feedback to improve behaviour.
© RRC International
Unit IA – Element IA7: Human Factors
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Exam Skills
QUESTION
Here you can have another attempt at a 20 mark, Section B question; this one is on the topic of human error.
Remember you would allow yourself 30 minutes to answer this question in the exam.
Question
Outline the desirable design features of controls AND displays on a control panel for a complex
industrial process aimed at reducing the likelihood of human error.
SUGGESTED ANSWER OUTLINE
Remember that there are 20 marks available so try to
mention 22 points in outline to maximise the chance of
getting full marks.
With this question on ergonomics, you need to focus on
features of controls and displays that would reduce the rate
of human error, including examples and reasons in your
answer.
The Examiner would be looking for an answer including
points similar to the following:
(20)
• Displays should indicate normal and abnormal
situations.
• Environmental concerns - located away from heat, glare
or anything else that may detract from recognition of
any signal.
• Displays should be located an appropriate distance
away from operator for ease of reading/correct sized
display.
• Discussion/consultation with users to obtain feedback
on suitable design and operation to avoid confusion.
• Controls – keep to a minimum, whilst still ensuring safe
operation and control.
• Controls should have a positive action.
• The user requires immediate feedback.
• Stop functions should:
––
––
––
––
Be easy to activate.
Have clear markings and functions.
Be designed to avoid accidental operation.
Be positioned away from interference by nonauthorised users.
–– Avoid non-intentional restart or shut down.
• Controls should be visible and in a logical order such
that operators interact with them – up/down buttons
not side by side with each other.
• Select the correct type of control for the operation
desired – levers versus knobs.
• Follow colour coding standards: green – on; red –
emergency stop, etc.
• Controls located adjacent to the displays, so operator
can see consequences of their actions.
• Clearly labelled.
• Language/terminology appropriate for understanding
and recognition.
• Displays should attract a response when required:
flashing, noise, etc.
• Correct type of display – analogue versus digital.
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| Unit IA – Element IA7: Human Factors
© RRC International
v2.1
Exam Skills
POSSIBLE ANSWER BY EXAM CANDIDATE
For a control panel and controls to be used effectively to manage the process and ensure safety, they need to be
designed from the operator’s point of view; this design should focus on the ergonomic layout of the panel and
controls, such that they are easy to reach, move and manipulate. The numbers of controls or interactions should be
kept to a minimum to prevent mental overload or having too much to monitor/review.
Controls that are safety critical, such as emergency stop buttons, should be clearly identified and be easy to operate
from any position. The emergency stop function should over-ride all other control functions. Other start and stop
controls should be designed differently, with start buttons recessed in order to prevent accidental operation. Controls
should be labelled in the correct language for the users, and be designed to accepted cultural norms, e.g. red for stop,
green for go, clockwise to increase, etc. It should also be clear to the user that the operation of the control has been
recognised by the process by providing feedback to the user.
The layout of the panel should be logical and follow the operator’s sequence if possible and the right type of control
for operation - dials for rotating things rather than buttons to push.
Other things that need to be considered would involve the environmental conditions in which the panel will be sited
and operated, light, fumes, indoors/outdoors, etc.; the controls need to be suitable for the environment (buttons
fading in sunlight).
Alarm signals must be clear and obvious and give operators time to react to the condition as well as being relevant to
the emergency, so they don’t become blasé to them going off and just mute them and forget. An alarm to warn of a
change of condition should therefore be different to that signalling an emergency situation.
You would also need to think about the operator from the point of view of markings for eyesight, too small so
unable to read, sticky labels that may fall off and be put on the wrong way round, colours – use of standards.
When considering the design of control panel displays it is essential that safety critical information is located in a
prominent position where it is not confused with other process information. The display should also be designed
using cultural norms and so that the status of the process is clear, e.g. by using green lights to show equipment that is
“on” and red to show equipment “off”.
The display should follow the process flow sequence so that the operator can relate the information on the control
display to the controls that he operates and the process that he understands.
The display must be clear and easy to read, e.g. free from flicker, glare and reflections. The use of process diagrams
rather than text may also aid understanding.
Finally alarm conditions on displays should be clear and prominent – it may be desirable to have a “warning”
alarm sequence and also a different “critical” alarm utilising beacons and audible alarms, making it very clear that
emergency action must be taken.
REASONS FOR POOR MARKS ACHIEVED BY CANDIDATES IN EXAM
An exam candidate answering this question would achieve poor marks if they made the mistake of describing the features
of a control room or panel, rather than the design features of controls and control panels.
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Unit IA – Element IA7: Human Factors
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v2.1
REGULATING HEALTH AND SAFETY
ELEMENT
8
LEARNING OUTCOMES
On completion of this element, you should
be able to demonstrate understanding
of the content through the application
of knowledge to familiar and unfamiliar
situations and the critical analysis and
evaluation of information presented in
both quantitative and qualitative forms. In
particular you should be able to:

Describe
comparative governmental and socio-legal,
regulatory and corporate models.
the role and limitations of the International
Explain
Labour Organisation in a global health and safety
setting.

© RRC International
Explain
the role non-governmental bodies and self
regulation has in securing common health and safety
standards in a global economy.
Unit IA – Element IA8: Regulating Health and Safety
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Contents
COMPARATIVE GOVERNMENTAL AND SOCIO-LEGAL AND CORPORATE REGULATORY MODELS
8-3
8-3
Role, Function and Limitations of Legislation
Nature, Benefits and Limitations of ‘Goal-Setting’ and ‘Prescriptive’ Legal Models
8-4
Loss Events in Terms of Failures in the Duty of Care to Protect Individuals and Compensatory Mechanisms that May be
8-5
Available
Mechanisms Used to Enforce Health and Safety Legislation
8-8
Laws of Contract
8-10
Revision Questions
8-11
ROLE AND LIMITATIONS OF THE INTERNATIONAL LABOUR ORGANISATION IN A GLOBAL HEALTH
8-12
AND SAFETY SETTING
Role and Status of Ratified Conventions, Recommendations and Codes of Practice in Relation to Health and Safety
8-12
Roles and Responsibilities of ‘National Governments’, ‘Enterprises’ and ‘Workers’: R164 Occupational Safety and Health
Recommendation 1981
8-14
Use of International Conventions as a Basis for Setting National Systems of Health and Safety Legislation
8-15
Revision Questions
8-15
ROLE OF NON-GOVERNMENTAL BODIES AND HEALTH AND SAFETY STANDARDS
8-16
Relevant Influential Parties
8-16
Importance of the Media in a Global Economy
8-17
8-18
Benefits of Schemes Which Promote Co-Operation on Health and Safety Between Different Companies
Effects on Business of Adverse Stakeholder Reaction to Health and Safety Concerns
8-18
Origins and Meaning of ‘Self-Regulation’
8-19
Role and Function of Corporate Governance in a System of Self-Regulation
8-20
How Internal Rules and Procedures Regulate Health and Safety Performance
8-21
How Non-Conformity to an Accredited Health and Safety Standard can be Used as a Form of Enforcement Within a Self8-22
Regulatory Model
Revision Questions
8-23
SUMMARY
8-24
EXAM SKILLS
8-25
8-2
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Comparative Governmental and Socio-Legal and Corporate
Regulatory Models
KEY INFORMATION
• Since organisations may not adopt good health and safety standards voluntarily, one way of making sure
minimum health and safety standards are met is for the government to introduce legislation (the statutes and
other legal instruments that have been enacted by the governing body).
• Goal setting legislation sets an objective, but leaves it to the dutyholder to decide on the best way of achieving
the defined goal.
• Prescriptive legislation defines the standard to be achieved in far more explicit terms.
• Federal systems aim to ensure uniform standards and regulation throughout the country, since if each state can
set their own standards, this will inevitably lead to inconsistencies.
• If a worker has a work-related accident or disease this may result in loss to the individual or dependants. There are
a number of mechanisms that allow individuals to seek restitution for damages including no fault or fault liability
claims
• Mechanisms that may be used to enforce health and safety legislation include criminal action and the use of
enforcement notices
• Contract law has many implications in respect of occupational health and safety including contracts of
employment, and establishing the relationship between producer and vendor, vendor and consumer, and client
and contractor.
ROLE, FUNCTION AND LIMITATIONS OF
LEGISLATION
It is not realistic to expect organisations to adopt good
health and safety standards voluntarily, not least because
the benefits of good (and costly) standards may not be
immediately obvious to all employers. One way of making
sure minimum standards are met, whether they relate
to health and safety or other matters to do with the
regulation of society, is for the government to introduce
legislation.
GLOSSARY
LEGISLATION
May be defined as the statutes and other legal
instruments (documents) that have been enacted by
the governing body.
Examples of legislation relating to occupational health and
safety include:
• Health and Safety at Work, etc. Act 1974 (United
Kingdom).
• Occupational Safety and Health Act 1970 (USA).
• Work Environment Act 1977 (Sweden).
By defining minimum acceptable standards, legislation at
least partly forces organisations to adopt good practice,
when otherwise they might be unlikely to do so voluntarily.
© RRC International
Legislation may be introduced that leads to criminal
and/or civil consequences. A crime is an offence against
the state and the consequence of a criminal action is
the prosecution of the offender, which may lead to
punishment, perhaps a fine or a prison sentence. What
behaviour constitutes a criminal offence is largely
dependent on the government and can therefore be
influenced by political concerns. In contrast, a civil action
is concerned with an individual who has suffered some
loss, such as being injured following a workplace accident.
The aim is for the claimant (the one who has suffered the
loss) to seek (usually) financial compensation from the
defendant as a result of the wrongdoing.
There are, however, limitations to the legislative approach.
The first is that there is little incentive for organisations
to go beyond the minimum legal requirements; they
will comply with what the law says, but not with its
spirit. In fact, since good standards often cost a lot of
time and money, an organisation which embraces such
high standards may be at a competitive disadvantage.
If a government introduces legislation then there is a
requirement for the legislation to be enforced. This
requires a means of identifying those who do not comply
with the law. Accordingly, enforcement officers who
have defined powers of inspection and investigation
(so that breaches of the law can be identified) must be
employed and trained. There must also be procedures
for the prosecution and punishment of organisations
and individuals who fail to meet the required standards,
i.e. an effective court system. The governments of some
countries do not appear to be able to enforce health and
safety provisions. Even in wealthy countries with extensive
resources, the enforcement of health and safety has to
compete with other government priorities.
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Comparative Governmental and Socio-Legal and Corporate
Regulatory Models
NATURE, BENEFITS AND LIMITATIONS OF
‘GOAL-SETTING’ AND ‘PRESCRIPTIVE’ LEGAL
MODELS
Nature
In practice legislation should not be thought of as being
entirely goal setting or entirely prescriptive - it more often
has the characteristics of both models. One example
is Regulation 8 of the Provision and Use of Work
Equipment Regulations 1998 (see above).
Legislation is sometimes described as being ‘goal setting’
or ‘prescriptive’. Goal setting legislation sets an objective
but leaves it to the dutyholder to decide on the best way
of achieving the defined goal. (Note that a dutyholder
is the person on whom the legal duty is placed, e.g. the
employer in the case of most health and safety duties.)
This states:
You can see a good example of goal-setting legislation
in the United Kingdom system. The principal Act of
Parliament governing health and safety is the Health and
Safety at Work, etc. Act 1974. The key duty imposed on
employers is:
This requires that employers provide adequate information
for users of work equipment - it has an element of
prescription in that there is a duty to provide information;
however, what constitutes “adequate” needs to be decided
by the employer, which effectively sets a goal.
“It shall be the duty of every employer to ensure, so
far as is reasonably practicable, the health, safety and
welfare at work of all his employees.”
The goal to be achieved is to ensure (so far as is reasonably
practicable) health and safety, but the Act does not
define how this should be done. It is up to the employer
to identify and evaluate different ways of meeting this
requirement and then to choose what is appropriate in
the given circumstances. (Note that the phrase “so far
as is reasonably practicable” is not only a feature of UK
legislation, but also of other regions. It generally means
that when deciding whether you need to take any action
to control a risk, you must compare the risk against the
effort, time and money that would be required to bring it
under control. So, some judgment is needed.)
In contrast, prescriptive legislation, as the name
suggests, defines the standard to be achieved in far more
explicit terms. One example, again from the UK, is in the
Provision and Use of Work Equipment Regulations
1998. Regulation 26 is concerned with the provision of
information and instruction to users of equipment for
use at work preventing mobile work equipment (e.g. fork
lift trucks) from rolling over. This regulation applies only
to such equipment and makes explicit what a dutyholder
should do to comply.
Regulation 26, Rolling over of mobile work equipment:
(1) Every employer shall ensure that where there
is a risk to an employee riding on mobile work
equipment from its rolling over, it is minimised by:
(a) stabilising the work equipment;
(b) a structure which ensures that the work
equipment does no more than fall on its side;
(c) a structure giving sufficient clearance to
anyone being carried if it overturns further
than that; or
(d) a device giving comparable protection.
8-4
(1)
Every employer shall ensure that all persons
who use work equipment have available to
them adequate health and safety information
and, where appropriate, written instructions
pertaining to the use of the work equipment.
Benefits and Limitations
TOPIC FOCUS
Prescriptive legislation has clearly defined
requirements which are more easily understood
by the dutyholder and enforced by the regulator.
It does not need a higher level of expertise to
understand what action is required, and provides a
uniform standard to be met by all dutyholders.
Limitations - it is inflexible and so depending on
the circumstances may lead to an excessively high or
low standard. Also it does not take account of the
circumstances of the dutyholder and may require
frequent revision to allow for advances in knowledge
and technology.
Goal-setting legislation allows more flexibility in
compliance because it is related to the actual risk
present in the individual workplace. It is less likely
to need frequent revision and can apply to a much
wider range of workplaces.
Limitations – it is more difficult to enforce because
what is “adequate” or “reasonably practicable” are
much more subjective and so open to argument,
possibly requiring the intervention of a court to
provide a judicial interpretation. Dutyholders will
also need a higher level of competence in order to
interpret such requirements.
| Unit IA – Element IA8: Regulating Health and Safety
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Comparative Governmental and Socio-Legal and Corporate
Regulatory Models
Legal Hierarchy of State and Federal Laws
GLOSSARY
FEDERAL LAW
Law created by the federal government of a nation.
FEDERAL GOVERNMENT
Formed when a group of political units, such as
states or provinces, merge together in a federation,
surrendering their individual sovereignty and many
powers to the central government while retaining
or reserving other limited powers. Examples: United
States of America, Canada, Australia and India.
One of the difficulties in federal systems is to ensure
uniform standards and regulation throughout the country.
If each state can set their own standards, there will
inevitably be inconsistencies.
In the USA, the Occupational Safety and Health Act
1970 was enacted at federal, rather than state level and
so the USA does not have significant problems with
harmonisation of standards. However, although the
Act applies to all states, its enforcement is delegated to
the individual states, which leads to inconsistencies in
enforcement standards.
There have been many attempts to harmonise
occupational health and safety standards in Australia. The
Ministers of Labour Advisory Committee, which comprises
state, territory and Commonwealth labour ministers,
agreed in 1990 that “as far as practicable, any standards
endorsed by the National Occupational Health and Safety
Commission (NOHSC) will be accepted as minimum
standards and implemented in the state/territory
jurisdiction as soon as possible after endorsement”. In
1991 the NOHSC set up a task force to develop a strategy
for harmonisation and by 1996 a number of priority
areas had been identified (e.g. hazardous substances) and
adopted by the states and territories. More recently, states
and territories agreed to work with the Commonwealth to
implement a model Occupational Health and Safety Act.
Within Europe there have been moves to harmonise
standards in different countries. This started with the
creation of the European Economic Community (EEC) (or
the Common Market) which was established by the Treaty
of Rome in 1957. This initially applied to six states, i.e.
France, West Germany, Italy, Belgium, the Netherlands and
Luxembourg. The Common Market then grew substantially
and became the European Union in 1993. There are
currently 27 member states. In terms of health and safety
integration, the Framework Directive of 1989 (89/391/
EEC) established measures to encourage improvements in
the safety and health of workers at work. On joining the
Union member states become subject to European Union
law and, where applicable, European law supersedes any
existing contrary domestic law.
© RRC International
However it is recognised that there are a number of
different legal systems within the EU. The EU issues
directives which are “binding as to the result achieved
upon each member state to which it is addressed, but shall
leave to the national authorities the choice of form and
methods”. This allows each member state to introduce its
own legislation as long as it achieves the broad objectives
contained within the directive. For example, within the
UK regulations are made under the enabling Health and
Safety at Work, etc. Act 1974.
LOSS EVENTS IN TERMS OF FAILURES IN THE
DUTY OF CARE TO PROTECT INDIVIDUALS
AND COMPENSATORY MECHANISMS THAT
MAY BE AVAILABLE
If a worker has a work-related accident or contracts a
disease as a result of their work, this may result in loss that
may include pain and suffering, as well as loss of future
income. The accident or ill health may lead to death, which
may result in the worker’s dependants suffering major
financial loss. There are a number of mechanisms that have
evolved to provide compensation to the injured worker, or
to his or her dependants. Some require the person making
the claim to prove that their accident or ill health was a
result of the fault of another, such as their employer. This
invariably means having to resort to litigation in the courts.
Others do not require proof of fault (no fault liability).
Compensatory Schemes
These can be conveniently divided into those schemes
where it is not necessary to prove that the employer
was at fault, and those in which the claimant (the injured
person) has to prove that the defendant was at fault, e.g.
negligence.
No-Fault Compensation Schemes
Although there is no need to prove fault, it is necessary
to establish that the harm was caused as a result of the
person’s employment.
Most no-fault workers’ compensation schemes fall into
one of two main categories:
• Employers provide the benefits; they pay premiums to
insurance companies, who in turn pay compensation to
the injured worker.
• The government or a government agency provides
the benefits. The system consists of social insurance
operated by the government or an agency of the
government.
Unit IA – Element IA8: Regulating Health and Safety
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Comparative Governmental and Socio-Legal and Corporate
Regulatory Models
Under both models the worker is required to report
the injury or ill health to their respective employer.
Most countries require the claim to be made within a
specified time, although this is often extended in cases of
occupational disease, when the time between exposure
to the hazard and the onset of the disease may be
considerable.
• Employers’ Schemes
Here the obligation to provide benefits is imposed
on employers. The scheme is operated by insurance
companies who are paid premiums by employers, and
in many jurisdictions this is compulsory. The insurance
companies are subject to regulation, usually by an
agency of the government. It is usual for all workers
in that industry to be covered by the scheme and in
some jurisdictions this includes the self-employed.
When a claim has been made by the worker or
dependants, the initial response is usually made by the
insurance company or sometimes by the employer. The
decision may be to accept or to reject the worker’s
claim, although it is common for there to be some
negotiation by the two parties concerned. Such
schemes are found in the USA and Australia.
• Social Insurance Schemes
These schemes are administered by government
and funded by compulsory contributions made by
employers, workers or both, with possible further
contributions made from general taxation. These
contributions may be at a fixed rate or may be
earnings-related. The scheme invariably requires
medical examinations to establish the nature of the
loss and whether any recovery is likely. Following the
decision by the administering government department,
the claimant can accept the decision or challenge it.
The employer usually has little interest, if any, in the
process. If the disability is permanent (e.g. hearing loss),
then a pension is usually paid, rather than a lump sum.
The UK operates an Industrial Injuries Disablement
Benefit Scheme. This is funded by National Insurance
contributions which are paid by employees and
employers and from taxation. The benefit is paid to
someone who has suffered a loss of faculty because
of an accident at work, or has a prescribed industrial
disease associated with the person’s occupation. It is
paid only to employees and not to the self-employed.
An “accident” is an incident or series of identifiable
incidents which has resulted in personal injury; a
“prescribed disease” is one from a defined list of about
70 diseases.
8-6
The claimant completes a claim form that is evaluated
to establish whether the injury was an accident, or in
the case of an occupational disease, to check that the
claimant has worked in the prescribed occupation. If
this is established, a medical examination is required
to identify the loss of faculty and the level of
disablement. Normally a person’s disablement has to
be 14% or more to receive benefit, except for certain
respiratory diseases, which require a 1% assessment
and occupational deafness, which requires a 20%
assessment.
Fault Compensation Scheme - Employers’
Liability
Most jurisdictions (including the USA, Australia and the
UK) have legislation that makes an employer liable for
injury or illness to a worker as a result of their occupation.
This requires the injured worker (or dependants following
a fatal outcome) to bring a civil action against the
employer and the need to establish fault on the part of
the employer, or one of his or her workers. The claimant
usually has to prove that the harm or illness was caused by
the negligence of the employer or one of his employees
or that there has been a breach of health and safety
legislation.
In the UK, the basis of the employer’s duty towards his
employees stems from the existence of a contract of
employment. However, virtually all cases are brought
under the law of tort (civil wrongs), in particular the tort
of negligence and the tort of breach of statutory duty. The
liability of the employer may come about in two ways:
• The employer is responsible for his or her own acts of
negligence - often called primary liability.
• The employer may be vicariously liable for the
negligent acts of his or her workers that are committed
in the course of their employment.
In an action for breach of statutory duty the claimant has
to prove:
• The statute places the obligation on the defendant.
• The statutory duty was owed to that claimant (i.e. the
claimant must show he is within the class of persons
whom the statute was intended to protect).
• The injury was of a type contemplated by the statute.
• The defendant was in breach of that duty.
• The breach of statutory duty caused the injury.
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Comparative Governmental and Socio-Legal and Corporate
Regulatory Models
In an action for negligence the claimant must prove:
• The defendant owed the claimant a duty of care; it is
well established that an employer owes a duty of care
to their workers and so if the defendant is an employer
this element is unlikely to be contested.
• The defendant was in breach of that duty - most
negligence cases hinge on this point. The important
point to note is that the standard required of the
defendant is an objective one, i.e. it depends on the
standard of care which would have been adopted by
the reasonable man in the circumstances.
• The claimant suffered damage as a result of the breach.
• The harm was foreseeable.
A claim will often be presented under both headings
(negligence and breach of statutory duty) at the same
time, although success under both results in only one
award of compensation. One of the key features of
employers’ liability is the extent of the compensation
(often called damages) awarded in a successful action. The
compensation awarded is meant to put the person back
into the same position they were in before they suffered
the loss. This can amount to considerable sums of money.
Damages
Damages may be classified as economic or noneconomic. Economic damages represent actual monetary
loss, whereas non-economic damages are those which
represent pain, suffering, and loss of companionship or
amenity.
Damages may also be categorised as compensatory and
punitive. As the name suggests, compensatory damages
compensate the claimant, whereas punitive damages are
meant to punish the wrongdoer.
© RRC International
TOPIC FOCUS
Compensatory Damages
The amount of compensatory damages is meant to
reflect the losses the claimant has suffered. The level
of award is determined by the court having received
evidence as to the extent of the losses.
Such damages can be classified as special damages
and general damages.
• Special Damages
The key feature of special damages is that they
can be relatively easily quantified because they
relate to known expenditure up until the trial,
such as:
–– Loss of earnings due to the accident or ill
health before the trial.
–– Legal costs.
–– Medical costs to date.
–– Building costs, if property has had to be
adapted to meet the needs of the injured
person.
–– Necessary travel costs associated with the
case.
The feature here is that invoices and receipts can
be presented to the court.
• General Damages
These include future expenditure and issues
which cannot be precisely quantified, such as:
–– Loss of future earnings as a result of the
incapacity.
–– Future medical costs.
–– Pain and suffering before and after the trial.
–– Loss of quality of life, e.g. loss of mobility,
inability to engage in sports which had been
pursued before the loss.
–– Loss of future opportunity, e.g. reduced
likelihood of being able to secure suitable
employment.
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Comparative Governmental and Socio-Legal and Corporate
Regulatory Models
Punitive Damages
Punitive damages are awarded to punish, to signify
disapproval, and to deter the defendant and others from
carrying out similar conduct to that which harmed the
claimant in the future. It is recognised that in certain
circumstances, punitive damages (or exemplary damages
in the UK) may be awarded where the compensatory
damages are considered to be inadequate and are awarded
by reference to the defendant’s behaviour. Since they
usually compensate the claimant’s losses beyond provable
losses, they are usually only awarded when the conduct of
the defendant was particularly oppressive, or where the
defendant made a profit from the behaviour.
In the USA, punitive damages are a matter for state
law and so there is no consistent application across the
country. In some states they are based on statute and in
others on case law.
MECHANISMS USED TO ENFORCE HEALTH
AND SAFETY LEGISLATION
Typical Role and Function of Enforcement
Agencies
As with all criminal law it is necessary to have a
government body that is responsible for regulating health
and safety at work.
In the UK this task falls to the government agency known
as the Health and Safety Executive (HSE). The HSE state
that “their job is to protect people against risks to health
or safety arising out of work activities”. They also “conduct
and sponsor research, promote training, provide an
information and advisory service and submit proposals
for new or revised regulations and approved codes of
practice”.
In the USA the enforcing body is the Occupational Safety
and Health Administration (OSHA) whose purpose is
“to reduce workplace fatalities, injuries, and illnesses by
promoting workplace safety and health”.
In Australia the UK model for enforcement was followed,
with most of the state Occupational Health and Safety
inspectorates now unified.
We will use the UK system to illustrate a typical model for
the enforcement of health and safety legislation.
8-8
TOPIC FOCUS
A Model for the Enforcement of Health and
Safety Legislation - Inspection and Investigation
Inspectors visit premises, often without an
appointment, for the following reasons:
• To conduct an inspection.
• To check that appropriate action has been taken
as a result of a previous visit.
• To investigate an accident, dangerous occurrence
or a case of occupational ill health.
• To investigate a complaint.
• At the request of the employer, union
representative, worker or member of the public.
Inspectors have extensive powers to carry out their
duties, including a right:
• Of entry into the premises at any reasonable
time.
• To take a policeman with them if there is
reasonable cause to believe that there might be
obstruction resulting in a breach of the peace.
• To carry out any investigations and examinations
as necessary (e.g. investigation of an accident or
a complaint).
• To direct that the premises are left undisturbed
for as long as is necessary to complete the
investigation so that evidence is preserved.
• To take measurements, photographs and record
information as necessary for the investigation.
• To take samples of any articles and substances.
• To cause an article to be dismantled and tested
or a substance to be analysed.
• To require any person whom the inspector
believes to have relevant information to give a
statement.
• To inspect and take copies of any entry in any
relevant book or document (e.g. accident book).
Inspectors have a number of ways of encouraging
dutyholders to comply with legal requirements.
The most widely used approach is that of providing
advice on what changes need to be introduced and
how these may be achieved. Inspectors often refer
to the vast amount of guidance literature that has
been published by the HSE and other bodies. This
advice is often confirmed in writing.
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Comparative Governmental and Socio-Legal and Corporate
Regulatory Models
Criminal Action
The ultimate sanction that the UK enforcement agencies
can impose is to prosecute. Since most duties under
health and safety law are imposed on employers, it is not
surprising that most prosecutions are brought against
employers. However, health and safety law also imposes
duties on workers, importers and manufacturers, etc.
Apart from there being evidence of a breach of statutory
duty, inspectors take account of the nature of the breach,
any resulting harm, past health and safety performance
and whether prosecution would be in the public interest
before deciding to prosecute.
TOPIC FOCUS
Enforcement Notices
Inspectors can exert more pressure by issuing
enforcement notices, which are in two categories.
Improvement Notices
Issued by an inspector if he is of the opinion that a
person:
• Is contravening one or more relevant statutory
provisions; or
Following a successful prosecution the usual penalty is a
fine, or in some circumstances (e.g. non-compliance with
an enforcement notice), the possibility of imprisonment.
Imprisonment is not an option for a company, because it
has a separate legal status to that of anyone who works for
it.
• Has contravened one of the provisions and it is
likely that the contravention will continue or be
repeated.
Fines are a limited form of penalty for several reasons. In
the UK, fines are usually relatively small compared to the
turnover and profitability of the company and so some
companies may take the chance of being prosecuted
rather than invest in health and safety. There is also no
evidence indicating that fines lead to improved standards
in health and safety. The following alternative penalties are
therefore also available.
• Specify the contravention;
The notice must:
• State the inspector is of that opinion;
• Give reasons as to why the opinion has been
formed; and
• The requirement for the contravention to be
remedied within a period of no less than 21 days.
The decision to issue a notice is therefore based
entirely on the inspector’s opinion.
The 21 days is to allow the person to appeal against
the notice (see below). If the person decides to
appeal then the notice is suspended until the appeal
is heard.
Prohibition Notices
Issued by an inspector if he is of the opinion that
activities are being carried out, or are likely to be
carried out, that involve a risk of serious personal
injury. There is no requirement to identify a specific
breach of law.
The notice must:
• State the inspector is of that opinion;
• Specify the matters which give rise to the risk of
serious personal injury; and
• Direct that the activities to which the notice
relates shall be stopped under the control of the
person on whom the notice is served, unless the
risk of serious personal injury has been removed.
The notice will indicate if it is to take effect
immediately, or after a specified time. As with
improvement notices, the person on whom the
notice is served may appeal against the notice.
However, a prohibition notice is not suspended
pending the outcome of the appeal.
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Comparative Governmental and Socio-Legal and Corporate
Regulatory Models
Appeals Against Notices
The person on whom the notice is served has the
opportunity of appealing against it to an employment
tribunal. In the UK, such tribunals have the same status as
courts, but deal solely with issues to do with employment.
The tribunal will then decide, on the basis of the evidence
presented to it, to affirm, modify, or cancel the notice.
Appeals are usually held in public and either side may be
represented by a lawyer.
Corporate Probation
This is a feature of the USA and Canadian jurisdictions, but
is a relatively new provision in the UK.
Corporate probation is a supervision order imposed by the
court on a company that has been convicted of a criminal
offence. The order requires the directors and senior
managers to alter the way occupational health and safety
is managed, so that the likelihood of similar accidents or
ill health occurring is reduced. This might, for example,
require the company to introduce new procedures or
ensure workers are fully trained. The court might decide
to suspend part of the fine so that if the company met
the requirements of the order, that part would not have
to be paid. However, if the company fails to comply with
the terms of the order, not only could the suspended
sentence be invoked, but further penalties could also be
imposed. This might include disqualifying one or more
directors from their roles. The key benefit of this type of
punishment is that it gives the court the power to set a
penalty that is matched to the particular company and
would hopefully achieve a positive change in the way in
which the company operates.
In the USA, corporate probation can be imposed on
corporations that have been found guilty of criminal
offences. The main objective in the USA is to force
convicted companies to pay compensation and prevent
them from hiding assets.
Adverse Publicity Orders
These are a feature of a number of jurisdictions including
the USA, Australia and more recently the UK. They
require the convicted organisation to publicise at their
own expense the wrongdoing that led to the conviction.
It is effectively “naming and shaming”. Established
companies invariably seek to promote themselves as being
well managed organisations that take health and safety
seriously. Establishing a good reputation is important if
they are to successfully compete with other organisations
by securing investment from shareholders and financial
institutions. Bad publicity will have a negative effect on the
image of the organisation and may have serious financial
implications for its future.
8-10
The use of adverse publicity orders was introduced in the
Corporate Manslaughter and Corporate Homicide Act
2007 which became UK law in April 2008. Following a
conviction for corporate manslaughter, the court has the
choice of imposing an adverse publicity order.
A court before which an organisation is convicted of
corporate manslaughter or corporate homicide may make
an order (a “publicity order”) requiring the organisation to
publicise in a specified manner:
• The fact that it has been convicted of the offence.
• Specified particulars of the offence.
• The amount of any fine imposed.
• The terms of any remedial order made.
LAWS OF CONTRACT
Contract law is a feature of many jurisdictions including
the UK, Australia and America. Contract law has many
implications in respect of occupational health and safety.
The relationship between an employer and employee or
contractors is based on a contract of employment. Similarly,
contracts are established between those who manufacture
articles or substances and those who buy them.
TOPIC FOCUS
Contract
In the legal context, a contract is an exchange
of promises, i.e. an agreement between two or
more parties which is enforceable in a court of
law. There must be a valid offer from one party,
and a valid acceptance before the contract is
established. The offer must be communicated
by one party to another and may be in writing,
verbal or by conduct. Business contracts are usually
communicated and accepted in writing because it
is much easier to prove that it has been created.
When we purchase an item in a shop we enter into a
contract with the vendor or seller. The receipt would
be proof of the existence of the contract.
The terms of a contract can be express or implied:
• Express terms are stated by the parties during
negotiation, or written into a contractual
document so it is clear what is required of each
party.
• Implied terms are not explicitly stated in the
contract, but are implied by custom, statute or
by the courts. For example, in the sale of goods
an implied term is that the seller has the right
to sell the goods and that in business sales the
goods are of satisfactory quality and are fit for
purpose.
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Comparative Governmental and Socio-Legal and Corporate
Regulatory Models
Principles of Typical Laws of Contract
If a contract is formed, then the parties who formed the
contract are legally bound by the terms of the contract
- the binding nature of a contract. If, subsequently, one
of the parties defaults on the contract then this would
constitute a breach of contract. It is not possible to bring
a legal action against somebody for breach of contract
who was not part of the contract. This is called privity of
contract. If the person who has caused the breach does not
provide a remedy then the person who has suffered a loss
as a result of the breach can bring a court action.
When an employer engages an employee, a contract of
employment is established.
Employer↔ Employee
One of the implied terms of such a contract is that the
employer will take reasonable care to ensure the health
and safety of the employee. Similarly, the employee is
required to carry out his or her work with reasonable care
and skill. A breach of contract, such as not adhering to the
safety rules may constitute a breach of contract resulting in
the employer dismissing the employee.
If the contract is breached and there is personal injury
then in the UK it is usual to bring a civil action under the
common law tort of negligence or breach of statutory duty,
rather than for breach of contract.
When articles and substances are manufactured there may
be a series of contracts established between the producer
(or manufacturer) and the consumer (or end user).
Producer ↔ Vendor ↔ Consumer
For example, if a person purchases a machine of a
particular make and model for use at work and the vendor
sells a machine that does not meet this specification, then
the consumer would be entitled to have the machine
replaced with the one ordered, or alternatively receive a
full refund of the moneys paid.
Similarly, it is common place for employers to engage
contractors for short-term work, particularly in the
construction industry.
Employer ↔ Contractor ↔ Subcontractor
The contract chain may be very short or, in the case of
articles and substances manufactured in another country,
the chain can involve importers and be much longer.
Each member engages in contracts with those above and
below in the chain. If a contract fails for such matters as
failure to supply the correct goods, poor quality work
or not completing the work within the time specified
by the contract, etc. a civil action for breach of contract
may follow. Remember, though, that personal injury cases
usually result in civil actions for negligence and breach of
statutory duty rather than for breach of contract.
REVISION QUESTIONS
1. What are the limitations of using legislation as
a means of ensuring acceptable occupational
health and safety standards?
2. Describe the benefits and limitations of
prescriptive and goal-setting legislation.
3. Identify and outline the two main no-fault
compensation schemes.
4. Describe the two categories of compensatory
damages.
5. What are meant by punitive damages?
6. Explain the term “corporate probation”.
(Suggested Answers are at the end.)
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Role and Limitations of the International Labour Organisation
in a Global Health and Safety Setting
KEY INFORMATION
• The adoption of a convention by the International Labour Conference (ILO) allows governments to ratify it and
for it to become a treaty in international law. All adopted ILO conventions are considered international labour
standards.
• Recommendations are non-binding guidelines, are not ratified by member countries, and do not have the binding
force of conventions.
• ILO codes of practice contain practical recommendations intended for all those with a responsibility for
occupational safety and health but are not legally binding instruments and are not intended to replace the
provisions of national laws or regulations, or accepted standards.
• Occupational Safety and Health Recommendation 1981 (R164) sets out the roles and responsibilities of
governments, enterprises and workers.
• International conventions can be used as a basis for setting national systems of health and safety legislation.
ROLE AND STATUS OF RATIFIED
CONVENTIONS, RECOMMENDATIONS
AND CODES OF PRACTICE IN RELATION TO
HEALTH AND SAFETY
ILO Role and International Labour
Conference
The International Labour Organisation (ILO) is an agency
of the United Nations (UN) that is devoted to advancing
opportunities for women and men to obtain decent and
productive work in conditions of freedom, equity, security
and human dignity. The ILO was created in 1919, as part of
the Treaty of Versailles that ended World War I. Its main
aims are to promote rights at work, encourage decent
employment opportunities, enhance social protection and
strengthen dialogue in handling work-related issues. The
ILO is the only “tripartite” United Nations agency in that it
brings together representatives of governments, employers
and workers to jointly shape policies and programmes.
The member states of the ILO meet at the International
Labour Conference, held every year in June in Geneva,
Switzerland. Each member state is represented by a
delegation consisting of two government delegates,
an employer delegate, a worker delegate, and their
respective advisers. Every delegate has the same rights,
and all can express themselves freely and vote as they
wish; worker and employer delegates may vote against
their government’s representatives, or against each other.
However, this diversity of viewpoints does not prevent
decisions being adopted by very large majorities, or in
some cases even unanimously.
Many of the government representatives are cabinet
ministers responsible for labour affairs in their own
countries. Heads of state and prime ministers also take the
floor at the conference. International organisations, both
governmental and others, attend as observers.
The conference allows for the creation of conventions
and recommendations - a two-thirds majority is required
before they can be adopted.
The ILO is the global body responsible for drawing up
and overseeing international labour standards. Working
with its 181 member states, the ILO seeks to ensure that
labour standards are respected in practice, as well as
principle. Since its early days, the ILO has sought to define
and guarantee labour rights and improve conditions for
working people by building a system of international
labour standards expressed in the form of conventions,
recommendations and codes of practice.
The ILO has adopted more than 180 ILO conventions and
190 recommendations covering all aspects of the world of
work. Nearly half of all ILO standards are concerned with
health and safety matters.
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Role and Limitations of the International Labour Organisation
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TOPIC FOCUS
ILO Conventions
The adoption of a convention by the International
Labour Conference allows governments to ratify
it, and when a specified number of governments
have done so, the convention becomes a treaty
in international law. All adopted ILO conventions
are considered international labour standards,
irrespective of how many governments have ratified
them.
Ratification of a convention imposes a legal
obligation to apply its provisions. However, it is
voluntary for a country to ratify a convention. If a
convention has not been ratified by member states,
it has the same legal force as recommendations.
Each government is required to submit a report
detailing their compliance with the obligations of
the conventions they have ratified. Each year the
International Labour Conference’s Committee on
the Application of Standards examines a number of
alleged breaches of international labour standards.
An example of a convention is the Occupational
Safety and Health Convention 1981 and its
protocol of 2002. This provides for the adoption of
a coherent national occupational safety and health
policy as well as action to be taken by governments
to improve working conditions.
International Labour Conference
Provisional Record 20A
Convention Concerning the Promotional Framework
for Occupational Safety and Health, ILO, Geneva, 2006
Article 4 sets out the following provisions in respect of a
national system.
“1. Each Member shall establish, maintain, progressively
develop and periodically review a national system
for occupational safety and health, in consultation
with the most representative organisations of
employers and workers.
2. The national system for occupational safety and
health shall include among others:
(a) laws and regulations, collective agreements
where appropriate, and any other relevant
instruments on occupational safety and health;
(b) an authority or body, or authorities or bodies,
responsible for occupational safety and health,
designated in accordance with national law
and practice;
© RRC International
3.
(c) mechanisms for ensuring compliance with
national laws and regulations, including
systems of inspection; and
(d) arrangements to promote, at the
level of the undertaking, co-operation
between management, workers and their
representatives as an essential element of
workplace-related prevention measures.
The national system for occupational safety and
health shall include, where appropriate:
(a) a national tripartite advisory body, or bodies,
addressing occupational safety and health
issues;
(b) information and advisory services on
occupational safety and health;
(c) the provision of occupational safety and health
training;
(d) occupational health services in accordance
with national law and practice;
(e) research on occupational safety and health;
(f) a mechanism for the collection and analysis
of data on occupational injuries and diseases,
taking into account relevant ILO instruments;
(g) provisions for collaboration with relevant
insurance or social security schemes covering
occupational injuries and diseases; and
(h) support mechanisms for a progressive
improvement of occupational safety and
health conditions in micro-enterprises, in
small and medium-sized enterprises and in the
informal economy.”
Copyright © International Labour Organisation 2006
Following the adoption of the above convention in 2006,
each member of the ILO is required to introduce measures
to implement its requirements within their own legislative
system.
TOPIC FOCUS
ILO Recommendations
Recommendations are non-binding guidelines
so are not ratified by member countries and
do not have the binding force of conventions.
Along with conventions, recommendations are
drawn up by representatives of governments,
employers and workers, and are adopted at the
ILO’s annual International Labour Conference. An
example is the Occupational Safety and Health
Recommendation R164 1981 which we look at
below.
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Role and Limitations of the International Labour Organisation
in a Global Health and Safety Setting
TOPIC FOCUS
(e)
ILO Codes of Practice
ILO codes of practice contain practical
recommendations intended for all those with a
responsibility for occupational safety and health
in both the public and private sectors. Codes of
practice are not legally binding instruments and are
not intended to replace the provisions of national
laws or regulations, or accepted standards. They aim
to serve as practical guides for public authorities
and services, employers and workers concerned,
specialised protection and prevention bodies,
enterprises and safety and health committees. Each
code is first prepared by the Office (of the ILO)
and finalised at a tripartite meeting composed of
experts nominated by the Governing Body (of the
ILO) in their personal capacity. Codes of practice are
submitted to the Governing Body for approval of
publication. An example is the Code of Practice on
Safety and Health in the Iron and Steel Industry
(2005).
ROLES AND RESPONSIBILITIES OF
‘NATIONAL GOVERNMENTS’, ‘ENTERPRISES’
AND ‘WORKERS’: R164 OCCUPATIONAL
SAFETY AND HEALTH RECOMMENDATION
1981
Occupational Safety and Health Recommendation
1981 (R164) sets out the roles and responsibilities of
governments, enterprises and workers. The key provisions
are as follows.
National governments should:
“(a) issue or approve regulations, codes of practice ........
on occupational safety and health and the working
environment, account being taken of the links ...
between safety and health, ... and hours of work
and rest breaks ...;
(b) ....... review legislative enactments concerning
occupational safety and health and the working
environment, ... in the light of experience and
advances in science and technology;
(c) undertake or promote studies and research to
identify hazards and find means of overcoming
them;
(d) provide information and advice, in an appropriate
manner, to employers and workers and promote
or facilitate co-operation between them and their
organisations, with a view to eliminating hazards
or reducing them as far as practicable; where
appropriate, a special training programme for
migrant workers in their mother tongue should be
provided;
8-14
(f)
(g)
provide specific measures to prevent catastrophes,
and to co-ordinate and make coherent the actions
to be taken at different levels, particularly in
industrial zones where undertakings with high
potential risks for workers and the surrounding
population are situated;
secure good liaison with the International Labour
Occupational Safety and Health Hazard Alert
System set up within the framework of the
International Labour Organisation;
provide appropriate measures for handicapped
workers.”
Enterprises:
“(a) to provide and maintain workplaces, machinery
and equipment, and use work methods, which are
as safe and without risk to health as is reasonably
practicable;
(b) to give necessary instructions and training, taking
account of the functions and capacities of different
categories of workers;
(c) to provide adequate supervision of work, of
work practices and of application and use of
occupational safety and health measures;
(d) to institute organisational arrangements
regarding occupational safety and health and the
working environment adapted to the size of the
undertaking and the nature of its activities;
(e) to provide, without any cost to the worker,
adequate personal protective clothing and
equipment which are reasonably necessary
when hazards cannot be otherwise prevented or
controlled;
(f) to ensure that work organisation, particularly with
respect to hours of work and rest breaks, does not
adversely affect occupational safety and health;
(g) to take all reasonably practicable measures with a
view to eliminating excessive physical and mental
fatigue;
(h) to undertake studies and research or otherwise
keep abreast of the scientific and technical
knowledge necessary to comply with the foregoing
clauses.
Copyright © International Labour Organisation 1981
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Role and Limitations of the International Labour Organisation
in a Global Health and Safety Setting
The measures taken to facilitate the co-operation referred
to in Article 20 of the Convention should include,
where appropriate, the appointment of workers’ safety
delegates or representatives of workers’ safety and health
committees, and/or of joint safety and health committees.
In joint safety and health committees, workers should
have at least equal representation with employers’
representatives.
Delegates and committees should:
“(a) be given adequate information on safety and
health matters, enabled to examine factors
affecting safety and health, and encouraged to
propose measures on the subject;
(b) be consulted when major new safety and health
measures are envisaged and before they are
carried out, and seek to obtain the support of
the workers for such measures;
(c) be consulted in planning alterations of work
processes, work content or organisation of work,
which may have safety or health implications for
the workers;
(d) be given protection from dismissal and other
measures prejudicial to them while exercising
their functions in the field of occupational safety
and health as workers’ representatives or as
members of safety and health committees;
(e) be able to contribute to the decision-making
process at the level of the undertaking regarding
matters of safety and health;
(f) have access to all parts of the workplace and be
able to communicate with the workers on safety
and health matters during working hours at the
workplace;
(g) be free to contact labour inspectors;
(h) be able to contribute to negotiations in the
undertaking on occupational safety and health
matters;
(i) have reasonable time during paid working hours
to exercise their safety and health functions and
to receive training related to these functions;
(j) have recourse to specialists to advise on
particular safety and health problems.”
Workers should:
“(a) take reasonable care for their own safety and
that of other persons who may be affected by
their acts or omissions at work;
(b) comply with instructions given for their own
safety and health and those of others and with
safety and health procedures;
(c) use safety devices and protective equipment
correctly and do not render them inoperative;
(d) report forthwith to their immediate supervisor
any situation which they have reason to believe
could present a hazard and which they cannot
themselves correct;
(e) report any accident or injury to health which
arises in the course of or in connection with
work.”
Copyright © International Labour Organisation 1981
USE OF INTERNATIONAL CONVENTIONS AS
A BASIS FOR SETTING NATIONAL SYSTEMS
OF HEALTH AND SAFETY LEGISLATION
In the UK the body responsible for establishing and
enforcing health and safety standards is the Health and
Safety Executive. It is committed to bringing conventions
and recommendations before Parliament within a year,
or exceptionally 18 months, of adoption. The procedural
tool for achieving this is through a White Paper produced
by the Department for Work and Pensions (DWP). A
proposed new law is called a Bill. Bills must be agreed by
both Houses of Parliament and receive Royal Assent from
the Queen before they can become an Act of Parliament
and law.
REVISION QUESTIONS
7. Explain the role of the International Labour
Organisation in respect of health and safety at
work.
8. Explain the difference between an ILO
convention and a recommendation.
9. What is an ILO code of practice?
10. What duties are imposed on national
governments by R164 Occupational Safety and
Health Recommendation 1981?
11. What duties are imposed on enterprises
by R164 Occupational Safety and Health
Recommendation 1981?
12. What duties are imposed on workers by
R164 Occupational Safety and Health
Recommendation 1981?
(Suggested Answers are at the end.)
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Role of Non-Governmental Bodies and Health and Safety
Standards
KEY INFORMATION
• The following influential parties have a key role in regulating health and safety performance:
–– Employer bodies.
–– Trade associations.
–– Trade unions.
–– Professional groups.
–– Pressure groups.
–– The general public.
• The media play an important role in communicating health and safety issues and can influence changes in
attitudes to health and safety.
• There are benefits to be had in schemes which promote co-operation on health and safety between different
companies.
• Following any adverse health and safety incident there will be financial implications for the organisation. Some of
the losses can be quantified, but there will be a range of indirect costs whose effect cannot easily be determined.
• Self-regulation is the process whereby an organisation monitors its own adherence to health and safety standards,
rather than having an outside agency, such as a governmental body, monitoring and enforcing them.
• Corporate governance is the system by which organisations are directed and controlled by their board of
directors who make strategic decisions that affect the direction of the organisation. Their area of control should
include occupational health and safety as well as other corporate objectives such as being competitive and
making a profit.
• For an organisation to effectively manage occupational health and safety it must devise and implement rules and
procedures that enable workers to adhere to safe working practices.
• Non-conformity to an accredited health and safety standard can be used as a form of enforcement on a selfregulatory model since all safety management models include the capacity for monitoring, audit and feedback
which leads to continuous improvement.
RELEVANT INFLUENTIAL PARTIES
Employer Bodies
These represent the interests of employers. In the UK
the main body is the Confederation of British Industry
(CBI). The CBI helps create and sustain the conditions in
which businesses in the United Kingdom can compete and
prosper for the benefit of all.
The CBI is the main lobbying organisation for UK business
on national and international issues. It works with the UK
government, international legislators and policymakers to
help UK businesses compete more effectively.
Another well-known active employer organisation is the
Chamber of Commerce. You will find branches operating
in many countries throughout the world.
Trade Associations
Trade associations are formed from a membership of
companies who operate in a particular area of commerce
and exist for their benefit. They can promote common
interests and improvements in quality, health, safety,
environmental and technical standards through various
appropriate means, e.g. the publication of guidelines,
information notes, codes of practice, and regular briefing
notes on technical issues and regulatory developments.
Sharing of good practice can be facilitated together
with provision of news and events appropriate to their
members’ areas of activity.
Meetings, workshops and seminars can be arranged
depending on an association’s membership, both
internationally and at a national/regional level, to enable
networking and the exchange of information and ideas, e.g.
on technical and safety issues.
Safety is of prime importance in any industry and there
is usually a system for publicising and circulating safety
messages to members on a regular basis.
Membership of a trade association is generally available
to companies and organisations active in the relevant
industry.
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Role of Non-Governmental Bodies and Health and Safety
Standards
Trade Unions
General Public
A trades union is an organisation of workers who have
formed together to achieve common goals in key areas,
such as wages, hours and working conditions. The trade
union negotiates with the employer on behalf of its
members. This may include the negotiation of wages,
work rules, complaint procedures, rules governing hiring,
firing and promotion of workers, benefits, workplace
safety and policies. The agreements negotiated by the
union leaders are binding on the rank and file members
and the employer, and in some cases on other nonmember workers. In the UK, unions may appoint safety
representatives from amongst the workers who may
investigate accidents, conduct inspections and sit on a
safety committee.
Individual members of the public can have little influence
on the regulation of health and safety unless they can
influence others and so form a body of opinion (e.g. a
pressure group) that cannot be ignored.
Professional Groups
A professional group is an organisation of individuals who
work in a particular profession and have achieved a defined
level of competence. Members typically pay a subscription
to join the group and receive a range of benefits. In the UK,
the Institution of Occupational Safety and Health (IOSH)
is the largest body for health and safety professionals,
with over 30,000 members worldwide, including more
than 10,000 Chartered Safety and Health Practitioners.
It is an independent, not-for-profit organisation that sets
professional standards, supports and develops members,
and provides authoritative advice and guidance on health
and safety issues. IOSH has increased its international
presence in more recent years. It has local branches not
only in the UK, but also in the Middle East, Hong Kong and
the Caribbean. IOSH is formally recognised by the ILO as
an international non-governmental organisation.
Pressure Groups
A pressure group can be described as an organised group
of people who have a common interest but, unlike a
political party, do not put up candidates for election.
However, they seek to influence government policy or
legislation. They can also be described as ‘interest groups’,
‘lobby groups’ or ‘protest groups’. They carry out research,
lobby politicians and so aim to influence public and
ultimately, government opinion. One example in the UK is
the Centre for Corporate Accountability. This is concerned
with the promotion of worker and public safety. Its focus
is on the role of state bodies in enforcing health and safety
law and investigating work-related deaths and injuries.
It was formed following a number of high profile workrelated accidents that led to a large number of deaths, and
the perception that the companies concerned were not
taking safety seriously and that the penalties imposed by
the courts were inadequate.
© RRC International
IMPORTANCE OF THE MEDIA IN A GLOBAL
ECONOMY
The media play an important role in communicating health
and safety issues and can influence changes in attitudes
to health and safety. The media includes print media
(e.g. newspapers, books and journals), broadcast media
(e.g. radio and television) and of increasing importance
Internet-based media, such as the World Wide Web.
No country can successfully compete in a global economy
without the use of media as a communication tool. In
terms of occupational health and safety the following
points indicate some of the ways the media is used:
• Making health and safety guidance easily accessible
with minimal cost. Agencies such as OSHA (USA) and
the HSE (UK) produce guidance for all categories of
dutyholders in all types of employment. This is available
in hard copy and more commonly in electronic format
that can be downloaded. This allows dutyholders who
have limited expertise to access relevant information
and so comply with legal requirements.
• Publicising good and bad health and safety
performance, e.g. TV and radio may publicise major
accidents, prosecutions and public inquiries. Major
disasters may be publicly discussed not only in the
country in which they occurred, but internationally,
e.g. the Chernobyl disaster. Incidents with lesser
consequences may be publicised within the area in
which they occurred. Such publicity increases the
awareness of occupational health and safety issues and
reminds dutyholders of the possible consequences of
failing to pay attention to these issues.
• Assisting in educating members of the professional
body and promoting good health and safety standards
by publishing professional journals (e.g. Institution of
Occupational Safety and Health (UK)).
• Enabling anyone with an Internet connection access
to a huge range of information (good and bad) which
would otherwise be much less accessible.
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• Enforcement bodies making information on good
health and safety practice easily accessible to
dutyholders.
Supplier auditing is the process by which an organisation
establishes that its existing and new suppliers meet their
requirements. In the context of health and safety, this
would include ensuring that the quality of the products
and services it supplies meets legal requirements and other
standards. For example, this may include the company
sending an auditor to a manufacturer of machines to
ensure that it has adopted safe working practices and that
the machines are constructed from suitable materials and
meet designated safety standards.
• Companies publicising good health and safety
performance to promote their services and to secure
a competitive advantage by being seen as good
employers.
EFFECTS ON BUSINESS OF ADVERSE
STAKEHOLDER REACTION TO HEALTH AND
SAFETY CONCERNS
The media can be used to help change attitudes to
occupational health and safety; examples of this include:
• Making the public, and in particular dutyholders,
aware of enforcement action such as prosecutions,
convictions and civil actions, through the newspapers,
TV/radio and the Internet.
• Adverse publicity orders (see earlier) are a sanction
that the courts may impose against organisations that
fail to comply with legal requirements. They will have
an adverse effect on the perceived reputation of the
organisation.
BENEFITS OF SCHEMES WHICH PROMOTE
CO-OPERATION ON HEALTH AND SAFETY
BETWEEN DIFFERENT COMPANIES
Explicit co-operation between companies is not usual
because in a free market, companies compete with each
other for customers and so may be reluctant to share good
practices for fear of giving their competitors an advantage.
However there are many schemes that have been
established that promote co-operation between different
companies. Depending on the benefits received by the
participants, these may last for a short period, or carry on
indefinitely.
The establishment of such schemes may be facilitated and
encouraged by government bodies, or they may be set up
informally.
An example of such schemes is the so called good
neighbour schemes.
In the UK a number of schemes have been established to
encourage larger organisations to help smaller businesses
and contractors with health and safety expertise. Small
businesses do not have access to the same health and
safety expertise, so if a large organisation can provide
advice to a smaller one, then the smaller business
will benefit and the larger organisation will be able to
demonstrate its public responsibility.
Following any adverse health and safety incident, such
as an accident or case of occupational ill health, there
will be financial implications for the organisation. Even a
small incident in which a worker has to receive first aid
will invariably cost money, including lost production from
the injured person and from those who give first aid and
manage the incident. Personal injury cases may involve a
claim for damages by the injured person which will again
have a financial impact on the organisation. There may be
a loss of morale amongst workers in the organisation in
the belief that the organisation does not care about their
health and safety. This may then lead to key personnel
seeking employment elsewhere, even though they may
have not suffered any direct loss. Some of the losses
already mentioned, e.g. loss of production, can be relatively
easily quantified, but there will be a range of indirect
costs whose effect cannot easily be determined. One such
effect is on the stakeholders of an organisation. These are
individuals who have an interest in the organisation and
include:
• Workers who rely on the organisation for employment.
• Other businesses, including suppliers and contractors
who trade with the organisation.
• Businesses that benefit indirectly from the presence of
an organisation, e.g. local shops.
• Shareholders who own the organisation and wish to
see their investment yield a satisfactory financial return.
We will consider the effects on stakeholders by considering
two incidents.
Schemes have also been established between organisations
of similar size. They might involve sharing expertise and
equipment such as a noise meter. It is much less costly to
share such resources and all members of the scheme will
benefit.
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Perrier Mineral Water Incident, 1990
Piper Alpha Disaster, 1988
Perrier is a French company that produces and bottles
mineral water. In early 1990, very small quantities of
benzene (an industrial solvent and a known carcinogen)
were discovered in bottles of the water in the USA. As a
result, the company had to withdraw from sale every bottle
of its water, which cost an estimated 200 million US dollars.
The actual concentration of benzene, although above the
limit specified by the US Food and Drug Administration
(FDA), was well below that which might endanger health.
Unlike the Perrier water incident, the Piper Alpha disaster
had a huge impact on all involved and remains the world’s
worst offshore disaster. The initial explosion was caused
by a failure to manage a maintenance operation. However,
failings in design, communication and a lack of emergency
preparedness caused the small explosion to escalate into
much larger gas explosions that led to the loss of 167 lives
and the rig.
When the problem was first realised, some 70 million
bottles were withdrawn from shops in the USA and
without actually knowing the source of the contamination,
it was declared that it was due to a bottle of cleaning fluid
and was limited to the US. A few days later the real cause
was shown to be failure to replace charcoal filters that were
used to remove impurities. A subsequent press conference
declared that Perrier water “naturally contains several
gases, including benzene. Those have to be filtered out.”
This declaration proved disastrous. Mineral water such as
Perrier has a reputation based on purity and as consumers
would have difficulty in distinguishing one brand of mineral
water form another, the image of the product is crucial. It
was the misinformation provided by the company in the
early days of the incident that led to the image that the
water was unsafe.
As the water was not available, consumers for a few weeks
turned to other brands and found that there was little
difference in the product. By the time the product was
relaunched into the market, confidence had fallen which
was reflected in significantly reduced sales and a fall in the
share price.
Although not a major incident in terms of its effect on
human health, the inconsistency in the messages provided
by the company had a significant financial impact on the
business.
The effect on the company was huge and included:
• Compensation claims for death and personal injury.
• Loss of production.
• Loss of cash flow.
• Loss of the rig.
• Damage to the image of the organisation worldwide.
This led to the owners of the rig, Occidental Petroleum,
withdrawing their interests from the North Sea. The
offshore industry’s image in general was damaged and
resulted in the UK economy losing revenue.
ORIGINS AND MEANING OF ‘SELFREGULATION’
GLOSSARY
SELF-REGULATION
The process whereby an organisation monitors
its own adherence to health and safety standards,
rather than having an outside agency, such as a
governmental body, monitoring and enforcing
standards.
The benefit to the organisation of self-regulation is that it
can set and maintain its own standards without external
interference. Accordingly if problems arise, it can more
easily keep its own internal affairs private. It also avoids the
significant national expense of establishing an enforcement
agency.
In contrast, attempts to self-regulate may fail because
individual organisations may believe there is little
advantage in establishing good standards if similar
organisations choose to ignore them. Workers in a selfregulated organisation may experience poor standards with
an increased frequency of accidents and ill health.
Self-regulation of health and safety within a legal
framework was one of the recommendations of the
Robens Committee, which was established in 1970 in the
UK to “review the provision made for the safety and health
of persons in the course of their employment and to
consider whether any changes are needed”.
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Role of Non-Governmental Bodies and Health and Safety
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The Robens report identified that the existing system
relied too much on regulation by external government
bodies with too little reliance on organisations establishing
their own standards. A key recommendation in the report
was that those who create the risks of occupational
accidents and ill health should be responsible for regulating
them. Future legislation should establish conditions for
creating more effective self-regulation, rather than relying
on more negative regulation by enforcement bodies.
The UK agency the Health and Safety Executive
defined self-regulation as “the purposeful creation and
maintenance of standards of health and safety and the
accordance of priorities commensurate with the risks
generated by the activities of the organisation”.
We mentioned the UK’s Health and Safety at Work, etc.
Act 1974 earlier in this element as an example of goalsetting legislation. The Act encourages self-regulation.
Section 2 of the Act states: “It shall be the duty of every
employer to ensure, so far as is reasonably practicable, the
health, safety and welfare at work of all his employees”.
The Act sets out a broad objective, but does not prescribe
how it will be achieved. It is for the dutyholder (in this case
the employer) to decide what is reasonably practicable.
This requires an assessment of the magnitude of the risk
associated with the hazard in question and the cost of
either eliminating or reducing the risk to a level that is at
least “tolerable” (but preferably “acceptable”). Accordingly,
the onus is shifted towards the employer to assess risks and
to identify and implement appropriate control measures.
To achieve self-regulation the Robens Committee
recognised the importance of securing worker
participation in the implementation and monitoring
of health and safety arrangements. In many countries,
including the UK, this is achieved through representatives
of workplace safety (trade unionised or otherwise) and/or
safety committees (which include worker representation).
ROLE AND FUNCTION OF CORPORATE
GOVERNANCE IN A SYSTEM OF SELFREGULATION
Aside from external legislation which may dictate the
conduct of the company, an organisation is to a certain
extent self-regulating; it sets many of its own objectives
and standards and determines how it will achieve them.
GLOSSARY
CORPORATE GOVERNANCE
The system by which organisations are directed and
controlled by their board of directors and includes
the making of broad strategic decisions that affect
the direction of the organisation. It is on a higher
level than management, which relates to the
regular decisions and subsequent actions needed to
effectively run the business.
The board of an organisation, that comprises its directors,
provides this corporate governance which aims to create
a successful organisation. Their area of control includes
occupational health and safety as well as other corporate
objectives, such as being competitive and making a profit.
To ensure good health and safety performance, the
board of the organisation generally has to be satisfied
that the following matters are dealt with throughout the
organisation.
• A demonstration of commitment by senior
management to occupational health and safety and an
appreciation that it is as important as other business
objectives.
• Ensuring that health and safety is reviewed at board
level.
• Those in the organisation at all levels have access to,
and receive competent advice.
• All staff, including board members, are trained and
competent in their health and safety responsibilities.
• Ensuring that the workforce, and in particular health
and safety representatives, are adequately consulted
and that their concerns reach the right level within the
organisation including, where necessary, the board.
• Systems are in place to ensure that health and safety
risks are assessed and suitable control measures
introduced and maintained.
• An awareness of what activities take place in the
organisation, including those of contractors.
• Ensuring regular information is received regarding
matters such as accident reports and cases of workrelated ill health.
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• The setting of targets which allow the organisation to
improve standards and to benchmark the organisation’s
performance against others within the same business
sector.
• Ensuring that changes in working arrangements
that have significant implications are brought to the
attention of the board.
A report from EU-OSHA, Leadership and Occupational
Safety and Health (OSH) – An Expert Analysis, looks at
corporate leadership factors on which success depends and
identifies the following five broad guiding principles:
1. Leaders must take seriously their responsibility for the
establishment of a positive prevention culture and
employ leadership styles which take account of the
cultural context in different groups or nations.
2. Leaders should be seen to prioritise OSH policies
above other corporate objectives, and apply them
consistently across the organisation and over time.
3. High-level management must be directly involved
in implementing OSH policies which have the
unequivocal commitment of an organisation’s
board and senior management.
4. Leaders should set out to cultivate an open
atmosphere in which all can express their experience,
views and ideas about OSH and which encourages
collaboration between stakeholders, both internal and
external, around delivery of a shared OSH vision.
5. Leaders should show they value their employees,
and promote active worker participation in the
development and implementation of OSH measures.
MORE…
The EU-OSHA report, Leadership and Occupational
Safety and Health (OSH) – An Expert Analysis, looks
at corporate leadership factors and analyses the
results of 16 case studies from companies across the
EU, identifying success factors and examples of good
OSH leadership. The report is available at:
HOW INTERNAL RULES AND PROCEDURES
REGULATE HEALTH AND SAFETY
PERFORMANCE
For an organisation to effectively manage occupational
health and safety it must devise and implement procedures
that enable workers to adhere to safe working practices.
This will inevitably include defining rules, and procedures
that must be reasonably complied with. Merely stipulating
rules is not enough. The worker must clearly understand
and appreciate the need for the rules as well as have the
competence to comply with them. The working conditions
must encourage compliance. For example, a worker
required to use a machinery guard in a manufacturing
process is less likely to adhere to the rule if the rate at
which he can do the work is significantly impaired when
the guard is used. Also, of course, if there is a poor safety
culture in the workplace and few existing workers comply
with the rules, then it cannot be reasonable to expect a
new worker to comply.
For a rule to be effective it has to be enforced by the
organisation. This requires monitoring by supervisors
and managers who must have the necessary authority to
enforce the rules. This may include routine day-to-day
monitoring, formal inspections and random spot checks.
Failure to comply with internal rules may lead to sanctions
imposed by the employer which may include:
• Informal verbal warnings.
• Formal verbal and written warnings.
• Temporary suspension from work.
• Demotion.
• Dismissal.
Such sanctions have to be imposed fairly and must not
constitute bullying. They must also comply with the
national employment law. Suitable and fairly enforced
safety rules will reduce the likelihood of workers violating
them, which will create an environment in which safe
working becomes the norm. This will accordingly reduce
the likelihood of accidents and ill health.
https://osha.europa.eu/en/publications/literature_
reviews/leadership-and-occupational-safety-andhealth-osh-an-expert-analysis/view
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Role of Non-Governmental Bodies and Health and Safety
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HOW NON-CONFORMITY TO AN
ACCREDITED HEALTH AND SAFETY
STANDARD CAN BE USED AS A FORM
OF ENFORCEMENT WITHIN A SELFREGULATORY MODEL
In Element IA1 we discussed two safety management
systems (SMSs) - the ILO guidelines ILO-OSH-2001
Guidelines on Occupational Health and Safety
Management Systems and the OHSAS 18001
Occupational Health and Management Systems 2007.
These can be used as a means of internal enforcement.
All safety management models include the capacity
for monitoring, audit and feedback, which leads to
continuous improvement. Active monitoring and auditing
should identify deficiencies in the system, that should be
corrected.
If the SMS is certified by an independent external body,
then the organisation may lose its certification for repeated
non-compliances and non-conformances revealed during
an audit. An organisation needs to demonstrate a plan of
continuous improvement that addresses such deficiencies.
The threat of loss of certification will be a significant
motivator in itself.
To effectively implement such a system the following
would need to be included:
• Education and training of both workers and managers.
• Documenting and monitoring of activities.
• Procedures for investigations and deciding on
corrective actions.
• Good communication procedures.
• Keeping up to date on legislation and other regulatory
requirements.
• Keeping a register of accidents and ill health.
If a system is established that responds quickly to failures,
there will be substantial improvements in standards. It
is also necessary to include monitoring and auditing by
trained personnel who may be internal or external to the
organisation. Monitoring should in particular involve line
managers who on a day-to-day basis deal with health and
safety issues.
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TOPIC FOCUS
Non-conformity to an accredited health and
safety standard can be used as a means of internal
enforcement in the following ways:
• Stakeholders may require conformity with an
accredited health and safety standard and will
expect significant change within the organisation
if it fails to maintain the standard, and clients
and business partners may not do business
with the organisation unless the accreditation is
maintained.
• Insurance companies may require demonstration
of a standard of performance in line with the
requirements of the standard in order to provide
cover and may withdraw cover of statutory
insurance if there is non-compliance.
• Third party audits will identify areas of noncompliance and require solutions to be put in
place to maintain accreditation.
• Threat of removal of accreditation and
associated loss of business may help to improve
standards.
• Loss of reputation as a result of non-compliance
may damage the image of the organisation.
• Possibility of expulsion from associations or trade
bodies as a result of the loss of accreditation will
motivate compliance.
• Non-compliance with a recognised system and
the lack of credibility that may arise from this
may serve to encourage compliance, particularly
if business is affected.
• Accrediting bodies have actions at their disposal,
such as informal notification of failures, formal
notification of non-conformance and even the
withdrawal of accreditation, which can provide a
strong inducement to comply with the standard.
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Role of Non-Governmental Bodies and Health and Safety
Standards
REVISION QUESTIONS
13. How do employers’ bodies influence health and
safety practices and standards?
14. How do trade unions influence health and safety
practices and standards?
15. Explain the ways in which the media, e.g. TV,
Internet, etc. can influence health and safety.
16. What is meant by a “good neighbour scheme”?
17. Explain the meaning of the term “selfregulation”.
18. List the functions of the board of an organisation
for the effective governance of health and safety.
(Suggested Answers are at the end.)
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Summary
SUMMARY
This element has dealt with a range of topics related to the regulation of health and safety.
Comparative Governmental and Socio-Legal and Corporate Regulatory Models
In particular we have:
• Explained the role of legislation as a means of promoting positive health and safety outcomes.
• Examined the differences between ‘goal-setting’ and ‘prescriptive’ legal models.
• Considered loss events as failures in the duty of care to protect individuals and examined the compensatory
mechanisms that may be available to them, including no fault liability and fault liability claims.
• Described the different mechanisms that may be used to enforce health and safety legislation.
• Examined the laws of contract.
Role and Limitations of the International Labour Organisation in a Global Health
and Safety Setting
We have:
• Examined the role and status of ILO conventions, recommendations and codes of practice in relation to health
and safety.
• Noted Occupational Safety and Health Recommendation 1981 (R164) which sets out the roles and
responsibilities of governments, enterprises and workers.
• Noted how international conventions can be used as a basis for setting national systems of health and safety
legislation.
Role of Non-Governmental Bodies and Health and Safety Standards
We have:
• Considered influential parties, such as employer bodies, trade associations, trade unions, professional groups,
pressure groups and the public who have a role in regulating health and safety performance.
• Noted how the media can play an important role in communicating health and safety issues and can influence
changes in attitudes to health and safety.
• Considered the benefits of schemes which promote co-operation on health and safety between different
companies.
• Explained, with reference to actual examples, the possible effects on business of adverse stakeholder reaction to
health or safety concerns.
• Examined the origins and meaning of ‘self-regulation’.
• Described the role and function of corporate governance in a system of self-regulation.
• Considered how internal rules and procedures regulate health and safety performance.
• Examined how non-conformity to an accredited health and safety standard can be used as a form of enforcement
on a self-regulatory model.
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Exam Skills
QUESTION
We will now move on to look at a law question. Questions relating to the legal aspects of health and safety can be
off-putting because it is a topic that health and safety practitioners are least familiar with. However, if you plan your
answer, you shouldn’t find it difficult to get good marks.
Question
Companies are subjected to many influences in health and safety.
(a)
In contract law, state what is meant by express terms.
(2)
(b)
Outline how influential parties can affect health and safety performance in a company.
(8)
(c)
Outline how non-conformity to an accredited health and safety standard such as
BS OHSAS 18001 can be used as a form of enforcement in a self-regulatory model.
APPROACHING THE QUESTION
This is a long question but is reasonably well subdivided
so it gives you a clear idea where the marks have been
allocated. Part (a) asks you to simply state what is meant by
“express terms”. Part (b) requires more detail and relates
to section IA8.3 of the syllabus and the relevant influential
parties that can affect health and safety performance. Part
(c) examines another section of IA8.3 that is concerned
with how non-conformity to an accredited health and
safety standard can be used as a form of enforcement on a
self-regulatory model.
If you are familiar with this material from your course notes
and the syllabus then the answer to the question should be
straightforward.
SUGGESTED ANSWER OUTLINE
For part (a) the examiner expects a concise summary such
as:
Express terms are those specifically mentioned and agreed
by all parties at the time the contract is made. They may
take account of unusual circumstances but should not
include unfair terms.
For part (b) the parties that should be considered include:
• Employer bodies - who may set performance standards
for member organisations.
• Trade associations - who may also set performance
standards for members and may require self-regulation
and compliance with accredited management systems.
• Trade unions – whose representatives check workplace
conditions and provide advice and guidance.
• Professional groups – such as IOSH, who set
professional standards of performance and provide
advice and guidance.
• Pressure groups – who can organise campaigns to
generate bad publicity if necessary.
© RRC International
(10)
• The public – who, as customers, can influence the
success of an organisation by boycotting goods and
services.
• The ILO – who publish advice and guidance
and enforce standards in conventions and
recommendations.
• Insurance companies – who can stipulate specific
performance standards for insurance cover and may
remove statutory cover for non-compliance.
• The media – who may publicise incidents affecting the
health and safety of workers and others.
For part (c) the examiner is looking for an outline of how
non-conformity with an accredited health and safety
standard may be used as a form of enforcement in a selfregulatory model and candidates are expected to provide
examples such as:
• Stakeholders may require conformity with an
accredited health and safety standard and will expect
significant change within the organisation if it fails
to maintain the standard. Also clients and business
partners may not do business with the organisation,
unless the accreditation is maintained.
• Insurance companies may require demonstration of
performance in line with the requirements of the
standard as a condition of providing cover and may
withdraw cover of statutory insurance if there is noncompliance.
• Third party audits will identify areas of non-compliance
and require solutions to be put in place to maintain
accreditation.
• Threat of removal of accreditation and associated loss
of business may help to improve standards.
• Loss of reputation as a result of non-compliance may
damage the image of the organisation.
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Exam Skills
• Possibility of expulsion from associations or trade
bodies as a result of the loss of accreditation will
motivate compliance.
• Non-compliance with a recognised system and the
lack of credibility that may arise from this may serve
to encourage compliance, particularly if business is
affected.
• Accrediting bodies have actions at their disposal, such
as informal notification of failures, formal notification
of non-conformance and even the withdrawal of
accreditation which can provide a strong inducement
to comply with the standard.
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Exam Skills
POSSIBLE ANSWER BY EXAM CANDIDATE
(a) Express terms in contract law refer to the specific details mentioned and agreed in the contract. They cover
unusual circumstances, but shouldn’t include unfair terms.
(b) Different groups can affect the H&S performance of a company; these can be by employers’ bodies, who can set
standards to follow for its members, trade unions who influence their members and provide H&S advice, insurance
companies who impose conditions of operation, design and management on companies, ILO who publish advice
and guidance and enforcement of standards as well as the media who will publish information of company ethics and
conditions to the local or national community.
(c) Non-conformity can be used as a form of enforcement in a self-regulatory model by stakeholders who expect you
to be accredited to a set scheme and may look at management sanctions against the management team for noncompliance. Loss of accreditation may mean loss of business as companies may require this to work with you; you
may lose your licence to operate your business as non-compliance may mean the licence is revoked by the awarding
authority, as well as the bad PR this can bring the company from the local and possibly national community.
REASONS FOR POOR MARKS ACHIEVED BY CANDIDATES IN EXAM
• Failing to provide a comprehensive list of influential parties.
• Listing influential parties but not outlining how each of the parties is able to affect health and safety performance.
• Not appreciating that non-conformity with an accredited health and safety standard and the threat of loss of
accreditation will have an effect on business performance through the influences of some of the parties considered in
part (b).
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REVISION AND EXAMINATION
THE LAST HURDLE
Now that you have worked your way through the
course material, this section will help you prepare
for your NEBOSH examination. This guide
contains useful advice on how to approach your
revision and the exam itself.
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Revision and Examination
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International Diploma Revision and Examination
YOUR NEBOSH EXAMINATION
You will need to successfully complete a three-hour
examination for each of Units IA, IB and IC, as well as
completing Unit ID, a workplace-based assignment, before
you achieve the International Diploma.
Your examination will consist of one exam paper which
consists of two parts:
• Section A has six 10-mark compulsory questions,
designed to test your breadth of knowledge across the
full range of elements in the syllabus.
• Section B has five 20-mark questions, from which you
must answer three. These are designed to test your
depth of knowledge across the full range of elements
in the syllabus.
You are allowed three hours in which to complete the
exam and are given ten minutes reading time before the
exam begins.
As a guide, you will need to achieve a minimum of
45% to pass the Unit IA, IB and IC exams, and 50% in
the workplace-based assignment (Unit ID). When you
have passed Unit IA you will then be issued with a Unit
Certificate, showing a pass grade.
REVISION TIPS
Using the RRC Course Material
You should read through all of your course materials once
before beginning your revision in earnest. This first read
through should be done slowly and carefully.
Having completed this first revision reading of the course
materials consider briefly reviewing all of it again to check
that you understand all of the elements and the important
principles that they contain. At this stage you are not
trying to memorise information, but simply checking your
understanding of the concepts. Make sure that you resolve
any outstanding queries with your personal tutor.
Remember that understanding the information and being
able to remember and recall it are two different things. As
you read the course material you should understand it; in
the exam you have to be able to remember and recall it. To
do this successfully most people have to go back over the
material repeatedly.
Re-read the course materials and make notes that
summarise important information from each element. You
could use index cards and create a portable, quick and easy
revision aid.
Once you have been awarded a Unit Certificate for all four
Units (Units IA, IB, IC and ID), you will receive an overall
grade as follows:
Pass
185 to 239 marks
Credit
240 to 279 marks
Distinction
280 marks or more
The overall mark is calculated by adding together your two
Unit Percentage scores.
Remember that your overall grade includes Unit ID, the
workplace-based assignment. Although at this stage of
your studies you are quite a way off being ready to attempt
the assignment, be aware that you will need to apply what
you have learned throughout your Unit studies when you
write your assignment.
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v2.1
International Diploma Revision and Examination
Using the Syllabus Guide
We recommend that you purchase a copy of the Guide
to the NEBOSH International Diploma in Occupational
Health and Safety, which contains the syllabus for your
course. If a topic is in the syllabus then it is possible that
there will be an examination question on that topic.
Map your level of knowledge and recall against the syllabus
guide. Look at the Content listed for each Unit element in
the syllabus guide. Ask yourself the following question:
“If there is a question in the exam about that topic,
could I answer it?”
You can even score your current level of knowledge for
each topic in each Element of the syllabus guide and then
use your scores as an indication of your personal strengths
and weaknesses. For example, if you scored yourself as 5
out of 5 for a specific topic in Element 1, then obviously
you don’t have much work to do on that subject as you
approach the exam. But if you scored yourself at 2 out
of 5 for a topic in Element 3 then you have identified an
area of weakness. Having identified your strengths and
weaknesses in this way you can use this information to
decide on the topic areas that you need to concentrate on
as you revise for the exam.
Another way of using the syllabus guide is as an active
revision aid:
• Pick a topic at random from any of the International
Diploma elements.
• Write down as many facts and ideas that you can recall
that are relevant to that particular topic.
© RRC International
• Go back to your course materials and see what you
missed, and fill in the missing areas.
Your revision aim is to achieve a comprehensive
understanding of the syllabus. Once you have this, you are
in a position to say something on each of the topic areas
and attempt any question set on the syllabus content.
EXAM HINTS
Success in the exam depends on averaging half marks, or
more for each question. Marks are awarded for setting
down ideas that are relevant to the question asked and
demonstrating that you understand what you are talking
about. If you have studied your course material thoroughly
then this should not be a problem.
One common mistake in answering questions is to go into
too much detail on specific topics and fail to deal with
the wider issues. If you only cover half the relevant issues,
you can only achieve half the available marks. Try to give
as wide an answer as you can, without stepping outside
the subject matter of the question altogether. Make sure
that you cover each issue in appropriate detail in order to
demonstrate that you have the relevant knowledge. Giving
relevant examples is a good way of doing this.
We mentioned earlier the value of using the syllabus
to plan your revision. Another useful way of combining
syllabus study with examination practice is to create your
own exam questions by adding one of the words you
might find at the beginning of an exam question (such as
‘explain’ or ‘identify’ or ‘outline’) in front of the syllabus
topic areas. In this way, you can produce a whole range of
questions similar to those used in the exam.
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International Diploma Revision and Examination
BEFORE THE EXAM
DURING THE EXAM
You should:
• Know where the exam is to take place.
• Arrive in good time.
• Bring your examination entry voucher, which
includes your candidate number, photographic proof
of identity, pens, pencils, ruler, etc. (Remember, these
must be in a clear plastic bag or wallet.)
• Bring water to drink and sweets to suck, if you want to.
• Read through the whole exam paper before starting
work, if that will help settle your nerves. Start with the
question of your choice.
• Manage your time. The exam is two hours long. You
should attempt to answer all 11 questions in the two
hours. To do this, you might spend:
–– 25-30 minutes answering Question 1 (worth 20
marks), and then
–– 8-9 minutes on each of the ten remaining 8-mark
questions.
Check the clock regularly as you write your answers.
You should always know exactly where you are, with
regard to time.
• As you start each question read the question carefully.
Pay particular attention to the wording of the question
to make sure you understand what the examiner is
looking for. Note the verbs (command words), such as
‘describe’, ‘explain’, ‘identify’, or ‘outline’ that are used
in the question. These indicate the amount of depth
and detail required in your answer. As a general guide:
–– ‘Explain’ and ‘describe’ mean give an understanding
of/a detailed account of something.
–– ‘Outline’ means give the key features of something.
–– ‘Identify’ means give a reference to something
(could be name or title).
• Pay close attention to the number of marks available
for each question, or part of a question – this usually
indicates how many key pieces of information the
examiner expects to see in your answer.
• Give examples wherever possible, based either on
your own personal experience, or things you have read
about. An example can be used to illustrate an idea and
demonstrate that you understand what you are saying.
• If you start to run out of time, write your answers in
bullet-point or checklist style, rather than failing to
answer a question at all.
• Keep your handwriting under control; if the examiner
cannot read what you have written, then he or she
cannot mark it.
• You will not be penalised for poor grammar or
spelling, as long as your answers are clear and can
be understood. However, you may lose marks if the
examiner cannot make sense of the sentence that you
have written.
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SUGGESTED ANSWERS
NO PEEKING!
Once you have worked your way through the revision
questions in this book, use the suggested answers
on the following pages to find out where you went
wrong (and what you got right), and as a resource
to improve your knowledge and question-answering
technique.
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Unit IA – Suggested Answers
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Element IA1: Principles of Health and Safety Management
Question 1
Question 4
Any five from the following list of uninsured costs:
The health and safety policy usually comprises:
• Product and material damage.
• A statement of intent that sets out the aims and
objectives of the organisation regarding health and
safety.
• Lost production time.
• Legal costs in defending civil claims, prosecutions or
enforcement action.
• Overtime and other temporary labour costs to replace
the injured worker.
• An organisational structure that details the people with
health and safety responsibilities and their duties.
• Time spent investigating the accident and other
administration costs (including supervisor’s time).
• The systems and procedures in place to manage risks.
Effective health and safety policies contribute to business
performance by:
• Fines from criminal prosecutions.
• Supporting human resource development.
• Loss of highly trained and/or experienced staff.
• Minimising the financial losses which arise from
avoidable unplanned events.
• Effects on employee morale and the resulting
reduction in productivity.
• Bad publicity leading to loss of contracts and/or orders.
Question 2
• Ensuring a systematic approach to the identification of
risks and the allocation of resources to control them.
• Supporting quality initiatives aimed at continuous
improvement.
Corporate social responsibility encompasses those
voluntary actions that the business can take, over and
above compliance with minimum legal requirements,
to address both its own competitive interests and the
interests of wider society. Businesses should consider their
economic, social and environmental impacts, and act to
address the key sustainable development challenges based
on their core competencies wherever they operate.
Question 3
(a)
ILO–OSH-2001:
• Policy.
• Organising.
• Planning and implementation.
• Evaluation.
• Action for improvement.
(b)
OHSAS 18001:
• OH&S policy.
• Planning.
• Implementation and operation.
• Checking and corrective action.
• Management review.
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Element IA1: Principles of Health and Safety Management
Question 5
Question 6
Arguments for integration:
It may be necessary to liaise externally with:
• Cost-effective.
• Local officials.
• Career opportunities for specialists.
• Consultants/contractors.
• Objectives and processes of management systems are
the same.
• Fire service.
• Avoidance of duplication.
• Enforcing authorities.
• Should reduce the possibility of resolving problems
at the expense of creating new difficulties in other
disciplines.
Question 7
• Momentum in one element of an IMS may drive
forward other elements that might otherwise stagnate.
• Owe a loyalty to the workforce, the community they
serve and the environment they affect.
• Positive culture in one discipline may be carried over to
others.
Arguments against integration:
• Abide by relevant legal requirements.
• Existing systems may work well already.
• Not undertake tasks they do not believe themselves to
be competent to carry out.
• Specialists continue to concentrate on the area of their
core expertise and further specialist training may not
be needed.
• Uncertainties regarding key terms may be made worse
in an IMS.
• System requirements may vary across topics covered.
• Health, safety and environmental performance
are underpinned by legislation and standards, but
quality management system requirements are largely
determined by customer specification.
• Regulators and single-topic auditors may have difficulty
evaluating their part of the IMS when it is interwoven
with other parts of no concern to the evaluator.
• A powerful, integrated team may reduce the ownership
of the topics by line management.
• Negative culture in one topic may unwittingly be
carried over to others.
• Insurance companies.
Any five of the following:
• Give honest opinions.
• Maintain their competence.
• Accept professional responsibility for their work.
• Make those who ignore their professional advice aware
of the consequences.
• Not bring the professional body into disrepute.
• Not recklessly or maliciously injure the professional
reputation or business of another.
• Not behave in a way which may be considered
inappropriate.
• Not improperly use their position within the
organisation for commercial or personal gain.
• Avoid conflicts of interest.
• Not improperly disclose information.
• Make information which they hold necessary to
safeguard the health and safety of others available on
request.
• Comply with data protection principles and relevant
legislation.
• Maintain financial propriety with clients and employers
and where appropriate be covered by professional
indemnity insurance.
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Element IA2: Loss Causation and Incident Investigation
Question 1
Question 6
The five factors of Heinrich’s accident sequence are:
The basic requirements of P155 are that national
governments should ensure that employers:
• Ancestry and social environment - character traits.
• Fault of person - inherited or acquired faults.
• Unsafe act and/or mechanical or physical hazard.
• Accident - event causing injury.
• Injury - effect of accident.
Question 2
Bird and Loftus extended Heinrich’s theory to include
the influence of management in the cause and effect of
accidents. They suggested a modified sequence of events:
• Lack of control by management;
• Permitting basic causes (i.e. personal and job factors);
• Leading to immediate causes (such as substandard
practices, conditions or errors);
• Which are the direct cause of the accident;
• Which result in loss (which may be categorised as
negligible, minor, serious or catastrophic).
Question 3
Latent failures are failures in the organisation or
environment which remain dormant and are often either
unrecognised or not appreciated until they lead to an
active failure and a loss event. An example would be a
lack of adequate training for a particular task. Only when a
worker who undertakes the task commits an error due to
the lack of training, does the failing become apparent.
Question 4
Accident triangles show there is a ratio between unsafe
acts, minor incidents and more serious ones. If employers
aim to reduce the frequency of unsafe acts this will lead to
a reduction in more serious outcomes.
Question 5
Accident frequency rate:
Number of work-related injuries × 100,000
Total number of man-hours worked
Number of man-hours worked = 20 x 38 x 47 h = 35720h.
Accident frequency rate =
8 x 100,000
= 22.4
35720
• Record and notify occupational accidents, suspected
cases of occupational disease, dangerous occurrences
and commuting accidents. The minimum notification
data should comprise:
–– Enterprise, establishment, employer.
–– Person injured and nature of injury/disease.
–– Workplace, circumstances (accident/dangerous
occurrence/disease).
• Inform employees about the recording system and
notifications.
• Maintain records and use them to help prevent
recurrence.
Question 7
Notifiable diseases to be reported should at least include
the prescribed diseases listed under ILO Convention C121.
The schedule to C121 contains a list of diseases prescribed
in relation to an activity, for which injury benefit should be
payable. Examples include:
• Conditions due to physical agents and the physical
demands of work, e.g. due to ionising radiation,
vibration, noise.
• Infectious or parasitic diseases (in health, vet work,
etc.).
• Conditions due to substances, e.g. silicosis, asbestosis;
arsenic, chromium, lead poisoning; lung cancer and
mesothelioma caused by asbestos.
Question 8
Accident records should be used as a tool to help control
the accidents that are causing the injuries and damage.
Detailed and thorough study of the records as part of the
normal on-going accident prevention programme should
give the following useful information:
• Relative importance of the various injury and damage
sources.
• Conditions, processes, machines and activities that
cause the injuries/damage.
• Extent of repetition of each type of injury or accident
in each operation.
• Accident repeaters, i.e. those workers who tend to be
repeatedly injured or are involved in more accidents.
• How to prevent similar accidents in the future.
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Element IA2: Loss Causation and Incident Investigation
Question 9
There will always be an immediate cause for an accident,
but we are also interested in finding the underlying and
root causes, which is why we need to consider the chain
of events leading up to an accident. The domino effect
of Heinrich’s theory is a good example. Obviously any
remedy which starts at the earliest stages will not only
prevent this accident, but a lot of others which have
the same root cause. Often, accident reports tend
to concentrate on ‘cause of injury’, when the safety
practitioner is more interested in ‘cause of accident’. In
the case of a multiple cause accident, we do at the very
least need to consider if it involves an unsafe act, an unsafe
condition and an unsafe person, and how these interact.
Question 10
There are a number of items which will be required for an
investigation, including the following:
• Photographic equipment.
• Portable lights which may be necessary as electricity
may be switched off, or the accident scene may be in a
poorly lit area in a confined space, such as a manhole.
• Sketchpad, pencils and measuring equipment.
• Record-keeping equipment, which should include a
notebook and possibly recording equipment.
• Sample collection equipment, such as jars or other
containers that can be sealed to prevent loss,
evaporation or contamination. Paper bags, plastic bags,
envelopes and cartons may also be required.
• Tools for cleaning debris or spillages.
• Where explosive or flammable vapours and gases are
liable to be involved, some sort of portable gas/vapour
detection equipment should be available. Similarly,
where poisonous or radioactive materials may be
involved, the appropriate detection equipment should
be provided.
Question 11
Following the UK’s HSG245, accident investigation can
follow four complementary steps:
• Step 1: Gathering the information.
• Step 2: Analysing the information.
• Step 3: Identifying risk control measures.
• Step 4: The action plan and its implementation.
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Element IA3: Measuring and Reviewing Health and Safety
Performance
Question 1
Question 6
Any three from the following:
Benchmarking is the process of comparing your own
practices and performance measures with organisations
that display excellence and whom you might wish to
emulate.
• To assess the effectiveness and appropriateness of
health and safety objectives and arrangements in terms
of:
–– Hardware (plant, premises, substances).
–– Software (people, procedures, systems).
• To measure and reward success (not to penalise
failure).
Question 7
The two sources of information that the review process
uses are routine monitoring data and audit data.
• To use the results as a basis for making
recommendations for a review of current management
systems.
• To maintain and improve health and safety
performance.
Question 2
Active measures include inspection reports, safety tour
reports, audit data.
Reactive measures include accident and ill-health data,
complaints, near misses.
Objective measures include number of prosecutions over
the last five years, number of risk assessments completed/
reviewed during last year, number of individuals trained in
a specific safety-related course.
Subjective measures include effectiveness of safety
communication, presence of a good safety culture.
Question 3
Limitations of accident and ill-health data:
• Numbers tend to be small and so variations year to
year may not be significant.
• Data, especially relating to ill health, may reflect
working conditions from at least several years
previously.
• Under-reporting - incidents to which the consequences
may not be immediately obvious may not get
reported, or reporting may be implicitly discouraged to
demonstrate an apparent good performance.
Question 4
The main measurement techniques available for measuring
health and safety performance in the workplace are:
audits, inspections, safety tours, safety sampling and safety
surveys.
Question 5
An internal audit is conducted by personnel who work
for the organisation; an external audit is carried out by a
person(s), independent of the organisation, who has no
vested interest in the outcome and can therefore be seen
to be more objective.
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Unit IA – Suggested Answers
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Element IA4: Identifying Hazards, Assessing and Evaluating
Risks
Question 1
Question 5
Accident and ill-health data may be used to:
Characteristics of a “suitable and sufficient” risk
assessment:
• Classify industries according to risk.
• It should identify the significant risks arising from or in
connection with the work.
• Classify workplaces.
• Classify occupations.
• Consider accident trends.
• Consider parts of the body injured - use of protective
clothing.
• Determine hazards in a workplace by using ‘cause of
injury’.
• Consider where the fault lies.
• Measure the effect of preventative/control measures.
Question 2
Useful internal information sources when assessing risk
include:
• Accident and ill-health reports.
• The detail in the assessment should be proportionate
to the risk.
• Whenever specialist advisers are used, employers
should ensure that the advisers have sufficient
understanding of the particular work activity they
are advising on; this will often require the effective
involvement of everyone concerned.
• Risk assessments should consider all those who might
be affected by the activities, whether they are workers
or others, such as members of the public.
• The risk assessment should indicate the period of time
for which it is likely to be valid.
Question 6
• Absence records.
• Maintenance records, which usually show damage
incidents.
Question 3
A “tolerable risk” means that we, as a society, are prepared
to endure it because of the benefits and that further risk
reduction is grossly out of proportion in terms of time,
cost, etc.
Incidence indicates the number of new cases in a
population in relation to the number at risk, whereas
prevalence indicates the proportion of persons in a
given population who have a defined (usually ill health)
condition.
Question 4
The “4Ps” include:
• Premises, including:
–– Access/escape.
–– Housekeeping.
–– Working environment.
• Plant and substances, including:
–– Machinery guarding.
–– Local exhaust ventilation.
–– Use/storage/separation of materials/chemicals.
• Procedures, including:
–– Permits-to-work.
–– Use of personal protective equipment.
–– Procedures followed.
• People, including:
–– Health surveillance.
–– People’s behaviour.
–– Appropriate authorised person.
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Element IA4: Identifying Hazards, Assessing and Evaluating
Risks
Question 7
The starting point is to logically construct an event tree
which begins with pipework failure (f = 0.01/year).
It should look something like this (notice how it is possible
to simplify the figure by ‘pruning’ branches that would not
change the outcome):
Following the failure of the pipework there are two
possibilities which will result in an explosion. Firstly, the
released gas will immediately ignite (probability, p =
0.05) resulting in a jet flame on site. The frequency of
this occurrence is calculated simply: 0.01/year x 0.05 =
0.0005/year. Alternatively this can be expressed as one
event in 2000 years (calculated from 1/0.0005). This gives
the answer to the first part of the question. Notice that for
this option (ignition on site), the factors of the wind and
the industrial estate have no impact; they will not change
the result. So, there is no point in further branching of this
branch (see figure).
The other option is that the gas does not immediately
ignite but drifts off site. If the probability of immediate
ignition is 0.05, then the probability of non-ignition and
drifting off site must be 0.95 (remember the probability at
each node adds up to 1). In most cases the gas disperses
safely but there is a one in ten chance (p = 0.1) that it will
drift to a nearby industrial estate. Finally, having drifted
onto the industrial estate, there is an even chance (p =
0.5) that a source of ignition will cause a vapour cloud
explosion or flash fire. Following through this event path
on the figure, the frequency of this event occurring is
calculated as: 0.01/year x 0.95 x 0.1 x 0.5 = 0.000475/year.
This can, alternatively, be expressed as one event every
2105 years (approximately).
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Question 8
Hazard and operability studies are designed for dealing
with complex systems, e.g. a large chemical plant. They are
carried out by a multidisciplinary team that makes a critical
examination of a process to discover any potential hazards
and operability problems. A series of guide words are
applied to each part of the system to identify the possible
consequences of a failure.
Question 9
A fault tree identifies the sub-events that are necessary
to cause a specified undesired event such as an accident.
Logic gates are used to show how the sub-events combine
together to cause the undesired event.
An event tree is used to identify the possible outcomes
following an undesired event.
Both techniques may be used qualitatively and, if suitable
data is available, quantitatively.
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Element IA5: Risk Control
Question 1
The main risk management strategies are:
• Avoidance or elimination.
• Reduction.
• Risk retention – with or without knowledge.
• Risk transfer.
• Risk sharing.
Question 2
The factors to be taken into account when choosing
control measures are:
• Long/short term.
• Applicability.
• Costs.
• Effectiveness.
• Legal requirements/standards.
• Competence and training requirements.
Question 3
Three reasons why cost-benefit analysis is not as simple
as adding up all the benefits of a health and safety
programme and subtracting the costs are:
• Not all costs and benefits can be accurately estimated.
• Benefits may not be seen immediately.
• Some costs and benefits are one-off and others are
recurring.
Question 4
Risk assessment may be used to develop a safe system of
work through:
• Analysing the task – identifying the hazards and
assessing the risks.
• Introducing controls and formulating procedures.
• Instructing and training people in the operation of the
system.
• Monitoring and reviewing the system.
Question 5
A permit to work is a formal written document of
authority to undertake a specific procedure and is designed
to protect personnel working in hazardous areas or
activities.
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Element IA6: Organisational Factors
Question 1
Question 5
Internal influences include financial status, production
targets, trades unions, and organisational goals and safety
culture.
There are two main economic implications:
Question 2
External influences include the bodies that are involved
in framing legislation and those agencies responsible
for its enforcement. Other organisations that may
exert an influence on health and safety in the workplace
include the courts through their decisions, trade unions
by promoting the health and safety of their members,
insurance companies by influencing company control
measures, professional organisations and various pressure
and campaign groups. Public opinion also has a significant
influence.
• Accidents resulting from poor health and safety
management result in huge financial losses to everyone
concerned. Poor health and safety management is
often itself caused by a lack of economic resources
available for health and safety purposes both at
national and workplace levels.
• It is not difficult to compare the costs of preventing
accidents with the costs arising from them
(compensation, lost production, increased insurance
premiums, overtime, legal fees, fines, etc.). Prevention
of accidents and ill-health is an investment which
attracts enormous dividends both for the individual
employer and the national economy as a whole.
Question 3
Question 6
The formal structure is represented by the company
organisation chart, the distribution of legitimate
authority, written management rules and procedures, job
descriptions, etc. The informal structure is represented by
individual and group behaviour.
The main role of representatives on health and safety is to
work actively to prevent worker exposure to occupational
hazards. Typical activities include:
• Workplace observations and inspections.
• Examination of records.
Question 4
• Listening to complaints.
The legal reasons for ensuring that third parties are
covered by health and safety management systems are
that ILO Occupational Safety and Health Convention C155
(Article 17) and accompanying Recommendation R164
(Article 11) state:
• Reading information.
“Whenever two or more undertakings engage in
activities simultaneously at one workplace, they
should collaborate in applying the provisions regarding
occupational safety and health and the working
environment, without prejudice to the responsibility
of each undertaking for the health and safety of its
employees. In appropriate cases, the competent
authority or authorities should prescribe general
procedures for this collaboration.”
Copyright © International Labour Organisation 1981
So, both of these imply that account is taken of third
parties who happen to be working on the same premises.
This invariably will involve the exchange of information (on
hazards, etc.) as well as the co-ordination of emergency
arrangements and sharing of procedures.
• Asking those that they represent what their views are.
Question 7
Typical activities of these committees would include:
• Promoting health and safety in the workplace
(including providing training).
• Monitoring the workplace for hazards and legal
compliance (including inspections).
• Agreeing the health and safety policy and its
implementation.
• Working with management to resolve health and safety
problems/complaints.
• Involvement in planning proposed changes that may
impact on health and safety.
• Keeping union members informed about planned
actions.
Question 8
A safety circle is a small group of workers - not safety
representatives or members of safety committees - who
meet informally to discuss safety problems in their
immediate working environment. The idea is based on the
‘quality circles’ concept and allows the sharing of ideas and
the suggestion of solutions. Any insurmountable problem
would be referred to the safety representative or safety
committee.
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Element IA6: Organisational Factors
Question 9
Question 14
Positive consultation involves the willingness on both sides
- employer and worker - to consider problems together, to
make use of each other’s knowledge and expertise, and to
apply that collective wisdom to the problem in hand.
The most common way to assess safety climate is by using
a tool which includes a questionnaire survey asking workers
the extent to which they agree or disagree with a number
of statements which reflect the management of health and
safety.
Question 10
Question 15
• Workers.
Management commitment can be demonstrated by (three
from):
• Temporary workers.
• Contractors.
• Managers being seen and involved with the work and
correcting health and safety deficiencies.
• Customers.
• Suppliers.
• Providing resources to carry out jobs safely.
• Enforcement authorities.
• Ensuring that all personnel are competent.
• Employment agencies.
• Members of the public.
• Enforcing the company safety rules, and complying
with them personally.
Question 11
• Managers matching their actions to their words.
External sources of health and safety information include:
Question 16
• Legislation, codes of practice and guidance.
A positive health and safety culture is characterised by:
• National and international Standards.
• Management commitment and leadership.
• Manufacturers’ instructions.
• High business profile to health and safety.
• Guidance from safety and professional bodies, e.g. ILO,
WHO, IOSH.
• Provision of information.
• Guidance from industrial bodies.
• Involvement and consultation.
• Training.
Question 12
• Promotion of ownership.
Internal sources of health and safety information include:
• Setting and meeting targets.
• Health and safety policy document.
Question 17
• Compliance data.
The following are needed to effect cultural change:
• Cost data.
• Good planning and communication.
• Risk assessments.
• Monitoring results – noise, dust, lighting, atmospheric,
etc.
• Job descriptions.
• Strong leadership.
• A step-by-step approach.
• Action to promote change.
• Strong worker engagement.
• Job safety analyses.
• Ownership at all levels.
• Results of inspections/audits.
• Training and performance measurements.
• Accident and ill-health reports/statistics.
• Feedback.
• Training records.
• Management system performance data.
Question 13
A definition should centre on a description of the
attitudes, values and beliefs which members of an
organisation hold in relation to health and safety, and
which, when taken together, produce an organisational
culture that can be positive or negative.
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Element IA7: Human Factors
Question 1
• Psychology - a study of the human personality.
• Sociology - a study of the history and nature of human
society.
Question 2
Maslow’s hierarchy of needs
Question 3
Question 5
The three levels of behaviour in Rasmussen’s model are:
Perceptual set: sometimes called a ‘mindset’. We have
a problem and immediately we perceive not only the
problem, but the answer. We then set about solving the
problem as we have perceived it. Further evidence may
become available, which shows that our original perception
was faulty, but we fail to see alternative causes and
solutions. This is a basic cause or factor in many accidents
and disasters.
• Skill-based - the person carries out the operation in
automatic mode. Errors occur if there are problems
such as machine variation or environmental changes.
• Rule-based - the operator is multi-skilled and has a
wide selection of well-tried routines which can be used.
Errors occur if the wrong alternative is selected or if
there is some error in remembering or performing a
routine.
• Knowledge-based - a person copes with an unknown
situation where there are no tried rules or routines.
Trial and error is the only method.
Question 4
Human sensory receptors react to danger in the following
ways:
• Sight - observation of a warning sign.
• Hearing - sound of an audible alarm.
• Taste - recognition of a toxic substance in food.
• Smell - identification of a hazardous gas release.
• Touch - identification of a hot surface.
Perceptual distortion: the perception of a hazard may
be faulty because it gets distorted. Things which are to
our advantage always tend to seem more right than those
which are to our disadvantage. Management generally
tend to have a different perception of hazard from that of
workers, and when it affects work rates, physical effort or
bonus payments, the worker also suffers from perceptual
distortion.
Question 6
Human error which contributed to the incident included:
• Operators under considerable stress – they had
incorrectly diagnosed the problem and stuck to their
course of action although the evidence was apparently
to the contrary.
• Operator training was inadequate.
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Element IA7: Human Factors
Question 7
Question 10
Ways that employees could be motivated:
Shift work can be very demanding on an individual and can
affect their performance in the following ways:
• Workplace incentive schemes: encourage employees
to work harder in order to receive a payment or
benefit.
• Reward schemes: offer a reward for improvement or
reaching a target in a particular area.
• Job satisfaction: some people only require job
satisfaction to be motivated. Job satisfaction is very
individual to each person.
• Appraisal schemes: a formal means of placing value on
achievement or effort. It is generally carried out on an
annual basis and the results may be used to determine
the level of a pay rise or a promotion.
Question 8
Formal groups are established to achieve set goals, aims
and objectives. They have clearly defined rules, structures
and channels of communication.
Informal groups superimpose on the organisation
an informal structure of communication links and
functional working groups. These cross all the barriers
of management status and can be based on family
relationships, out-of-work activities, experience or
expertise.
Question 9
Peer group pressure can influence behaviour at work in the
following ways:
• Group formation - people tend to join groups with
those of a similar outlook. A lot of work situations
involve group work or committees and discussion
groups.
• Group reaction - the group tends to create its own
rules and arrangements, particularly in large groups,
which may be dominated by a few members. In smaller
groups people tend to be more able to have an input
into the group’s actions.
• Group development - groups develop ‘pecking orders’
in terms of the amount of speech and influence
permitted. Dominant individuals struggle for status
and an order develops.
• Fatigue and stress - poorer performance on tasks
requiring attention, decision-making or high levels of
skill.
• Sleep loss and sleep debt - lower levels of alertness, and
reduced levels of productivity and attention.
• Health problems - asthma, allergic reactions and
respiratory problems tend to be worse at night, and so
it is likely that performance will be affected where an
individual’s health is affected.
• Social life/family life - work performance may be
affected if the individual is unhappy at home due to the
constraints of shift work.
• Natural circadian rhythm - when working nights, the
body still reduces body temperature in the early hours
of the morning, reduces blood pressure and stops
digestion which can lead to an individual feeling sleepy
and less alert.
Question 11
There are various methods of payment for work and terms
of employment, and these may all affect performance in
different ways:
• Piecemeal workers - need to work quickly because
they are paid by the amount of work they do; speed is
important, but safety is also an issue, because if they
injure themselves they won’t be able to work and will
not get paid.
• Permanent contract employees - get paid whether
they are at work or sick (in general), so safety or
performance may not be an incentive for them. There
may, however, be incentive schemes in place which
reward good performance, safe working and/or
good attendance, and these may affect an individual’s
performance.
• Short-term contract workers - generally need to
perform well in order for their contract to be renewed
(unless there is a shortage of workers). This means that
there is pressure on the individual to perform to their
best ability.
• Group control - the group will establish standards
of acceptable behaviour or group ‘norms’, detect
deviations from this standard and have the power to
demand conformity.
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Element IA7: Human Factors
Question 12
Ergonomics is the study of the relationship between
workers and their environment, ensuring a good ‘fit’
between people and the things they use. Essentially it
involves “fitting the task to the man” rather than “fitting
the man to the task”. The order of operations and work
practices can be modified so that each person is working
to full efficiency. Poorly designed work equipment and
unsafe practices may result in injury and occupational illhealth. These may include:
• Equipment not suited to body size.
• Operator not able to readily see and hear all that they
need to.
• Lack of understanding of the information that is
presented to the employee.
• Equipment or system causing discomfort if used for any
length of time.
Question 13
The following features are present in an ergonomicallydesigned crane cab control system:
• The controls are within easy reach of the driver and are
moved in a straight line to allow ease and delicacy of
control.
• The seat is adjustable so that the driver has a good view
of the operations.
• The environment of the cab protects the driver from
dust and fumes, etc.
Question 14
The steps of a behavioural change programme relating to
safety are:
Step 1: Identify the specific observable behaviour that
needs changing, e.g. to increase the wearing of hearing
protectors in a high noise environment.
Step 2: Measure the level of the desired behaviour by
observation.
Step 3: Identify the cues (or triggers) that cause the
behaviour and the consequences (or pay offs) (good and
bad) that may result from the behaviour.
Step 4: Train workers to observe and record the safety
critical behaviour.
Step 5: Praise/reward safe behaviour and challenge unsafe
behaviour.
Step 6: Feedback safe/unsafe behaviour levels regularly to
workforce.
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Element IA8: Regulating Health and Safety
Question 1
Question 4
There is little incentive to go beyond minimum
legal requirements. The government has to employ
enforcement officers and introduce sanctions which may
be imposed by the courts.
The two categories are special and general damages.
Question 2
• Loss of earnings due to the accident or ill health before
the trial.
Prescriptive legislation has clearly defined requirements
which are more easily understood by the dutyholder and
enforced by the regulator. It does not need a higher level
of expertise to understand what action is required, and
provides a uniform standard to be met by all dutyholders.
However, it is inflexible and so depending on the
circumstances may lead to an excessively high or low
standard. In addition, it does not take account of
the circumstances of the dutyholder and may require
frequent revision to allow for advances in knowledge and
technology.
Goal-setting legislation allows more flexibility in
compliance because it is related to the actual risk present
in the individual workplace. It is less likely to need
frequent revision and can apply to a much wider range of
workplaces.
It is, however, much more difficult to enforce because what
is “adequate” or “reasonably practicable” are much more
subjective and so open to argument, possibly requiring the
intervention of a court to provide a judicial interpretation.
Dutyholders will also need a higher level of competence in
order to interpret such requirements.
Question 3
Employers’ and government schemes. In employer
schemes, employers pay premiums to insurance companies
who pay compensation to the injured worker. In
government schemes the government or a government
agency provides the benefits.
© RRC International
Special damages can be relatively easily quantified because
they relate to known expenditure up until the trial. They
include:
• Legal costs.
• Medical costs to date.
• Building costs, if property has had to be adapted to
meet the needs of the injured person.
• Necessary travel costs associated with the case.
General damages include future expenditure and issues
which cannot be precisely quantified. They include:
• Loss of future earnings as a result of the incapacity.
• Future medical costs.
• Pain and suffering before and after the trial.
• Loss of quality of life, e.g. loss of mobility, inability to
engage in sports which had been pursued before the
loss.
• Loss of future opportunity, e.g. reduced likelihood of
being able to secure suitable employment.
Question 5
Punitive damages are awarded to punish and deter the
defendant and other similar persons from such conduct
that harmed the claimant. They are awarded by reference
to the defendant’s behaviour and aim to deter similar
conduct in the future and to signify disapproval.
Question 6
Corporate probation is a supervision order imposed by the
court on a company that has been convicted of a criminal
offence. The order requires the directors and senior
managers to alter the way occupational health and safety
is managed so that the likelihood of similar accidents or
ill-health occurring is reduced. This might, for example,
require the company to introduce new procedures or
ensure workers are fully trained. The court might decide
to suspend part of the fine so that if the company met
the requirements of the order then that part would not
have to be paid. However, if the company fails to comply
with the terms of the order, not only could the suspended
sentence be invoked but further penalties could also be
imposed.
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Element IA8: Regulating Health and Safety
Question 7
Question 11
Its main aims are to promote rights at work, encourage
decent employment opportunities including good health
and safety standards, enhance social protection and
strengthen dialogue in handling work-related issues.
Roles and responsibilities of enterprises:
Question 8
A convention is an agreement in international law
which has to be ratified by member countries. A
recommendation, as the name suggests, does not require
ratification by member states.
Question 9
ILO codes of practice contain practical recommendations
intended for all those with a responsibility for occupational
safety and health in both the public and private sectors.
Codes of practice are not legally binding instruments and
are not intended to replace the provisions of national laws
or regulations, or accepted standards.
Question 10
Roles and responsibilities of national governments:
“(a) issue or approve regulations, codes of practice.....
on occupational safety and health and the working
environment, account being taken of the links ...
between safety and health, ... and hours of work
and rest breaks ...;
(b) .... review legislative enactments concerning
occupational safety and health and the working
environment,... in the light of experience and
advances in science and technology;
(c)
undertake or promote studies and research to
identify hazards and find means of overcoming
them;
(d)
provide information and advice, in an appropriate
manner, to employers and workers and promote
or facilitate co-operation between them and their
organisations, with a view to eliminating hazards
or reducing them as far as practicable; where
appropriate, a special training programme for
migrant workers in their mother tongue should be
provided;
(e)
provide specific measures to prevent catastrophes,
and to co-ordinate and make coherent the actions
to be taken at different levels, particularly in
industrial zones where undertakings with high
potential risks for workers and the surrounding
population are situated;
(f)
secure good liaison with the International Labour
Occupational Safety and Health Hazard Alert
System set up within the framework of the
International Labour Organisation;
(g)
provide appropriate measures for handicapped
workers.”
“(a) to provide and maintain workplaces, machinery
and equipment, and use work methods, which are
as safe and without risk to health as is reasonably
practicable;
(b) to give necessary instructions and training, taking
account of the functions and capacities of different
categories of workers;
(c) to provide adequate supervision of work, of
work practices and of application and use of
occupational safety and health measures;
(d) to institute organisational arrangements
regarding occupational safety and health and the
working environment adapted to the size of the
undertaking and the nature of its activities;
(e) to provide, without any cost to the worker,
adequate personal protective clothing and
equipment which are reasonably necessary
when hazards cannot be otherwise prevented or
controlled;
(f) to ensure that work organisation, particularly with
respect to hours of work and rest breaks, does not
adversely affect occupational safety and health;
(g) to take all reasonably practicable measures with a
view to eliminating excessive physical and mental
fatigue;
(h) to undertake studies and research or otherwise
keep abreast of the scientific and technical
knowledge necessary to comply with the foregoing
clauses.”
Copyright © International Labour Organisation 1981
Copyright © International Labour Organisation 1981
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Element IA8: Regulating Health and Safety
Question 12
Question 15
Roles and responsibilities of workers:
The media can influence health and safety by:
“(a) take reasonable care for their own safety and that
of other persons who may be affected by their acts
or omissions at work;
(b) comply with instructions given for their own safety
and health and those of others and with safety and
health procedures;
(c) use safety devices and protective equipment
correctly and do not render them inoperative;
(d) report forthwith to their immediate supervisor
any situation which they have reason to believe
could present a hazard and which they cannot
themselves correct;
(e) report any accident or injury to health which arises
in the course of or in connection with work.
Copyright © International Labour Organisation 1981
Question 13
These bodies represent the interests of employers. In the
UK the main body is the Confederation of British Industry
(CBI). The CBI helps create and sustain the conditions in
which businesses in the United Kingdom can compete and
prosper for the benefit of all. The CBI is the main lobbying
organisation for UK business on national and international
issues, including health and safety practices and standards.
Question 14
A trades union is an organisation of workers who have
formed together to achieve common goals in key areas
such as wages, hours, and working conditions. The
trade union negotiates with the employer on behalf
of its members. This may include the negotiation of
workplace safety and health issues and policies. In the UK,
unions may appoint safety representatives from amongst
the workers who may investigate accidents, conduct
inspections and sit on a safety committee.
• Making health and safety guidance easily accessible
with minimal cost. Agencies such as OSHA (USA)
and the HSE (UK) produce guidance for all categories
of dutyholders in all types of employment. This
is available in hard copy and more commonly in
electronic format that can be downloaded. This
allows dutyholders who have limited expertise to
access relevant information and so comply with legal
requirements.
• Publicising good and bad health and safety
performance, e.g. TV and radio may publicise major
accidents, prosecutions and public inquiries. Major
disasters may be publicly discussed not only in the
country in which they occurred but internationally,
e.g. the Chernobyl disaster. Incidents with lesser
consequences may be publicised within the area in
which they occurred. Such publicity increases the
awareness of occupational health and safety issues and
reminds dutyholders of the possible consequences of
failing to pay attention to these issues.
• Assisting in educating members of the professional
body and promoting good health and safety standards
by publishing professional journals (e.g. Institution of
Occupational Safety and Health (UK)).
• Enabling anyone with an Internet connection access
to a huge range of information (good and bad) which
would otherwise be much less accessible.
Question 16
In the UK a number of good neighbour schemes have
been established to encourage larger organisations to help
smaller businesses and contractors with health and safety
expertise. Small businesses do not have access to the same
health and safety expertise, so if a large organisation can
provide advice to a smaller one, then the smaller business
will benefit and the larger organisation will be able to
demonstrate its public responsibility.
Schemes have also been established between organisations
of similar size. They might involve sharing expertise and
equipment such as a noise meter. It is much less costly to
share such resources and all members of the scheme will
benefit.
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Element IA8: Regulating Health and Safety
Question 17
Self regulation is the process whereby an organisation
monitors its own adherence to health and safety
standards, rather than having an outside agency, such as
a governmental body, monitoring and enforcing them.
The benefit to the organisation is that it can set and
maintain its own standards without external interference.
Accordingly if problems arise, it can more easily keep its
own internal affairs private. It also avoids the significant
national expense of establishing an enforcement agency.
Self regulation of health and safety within a legal
framework was one of the recommendations of the
Robens Committee which was established in 1970 in the
UK to “review the provision made for the safety and health
of persons in the course of their employment and to
consider whether any changes are needed”.
Question 18
The functions of the board of an organisation which ensure
the effective governance of health and safety include:
• A demonstration of commitment to occupational
health and safety and an appreciation that it is as
important as other business objectives.
• Ensuring that health and safety is reviewed at board
level.
• Those in the organisation at all levels have access to
and receive competent advice.
• All staff including board members are trained and
competent in their health and safety responsibilities.
• Ensuring that the workforce, and in particular health
and safety representatives, are adequately consulted
and that their concerns reach the right level within the
organisation including, where necessary, the board.
• Systems are in place to ensure that health and safety
risks are assessed and suitable control measures
introduced and maintained.
• An awareness of what activities take place in the
organisation, including those of contractors.
• Ensuring that regular information is received regarding
matters such as accident reports and cases of workrelated ill health.
• The setting of targets which allow the organisation to
improve standards and to benchmark the organisation’s
performance against others within the same business
sector.
• Ensuring that changes in working arrangements
that have significant implications are brought to the
attention of the board.
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