Firestar

Every accident in history is a domino effect or a James Reason Swiss cheese"

Think of the domino's as barriers to safety so as an example you have the following (not exhaustive) (there are lots more than this)

Induction Orientation
On the job/task training
risk assessment
method statement SWP
pre job brief
Supervision
Engineering control
Audit regime

Therefore we will take an imaginary accident where some one got their fingers trapped in say "a lathe"
We then equate each of the line item barriers as a domino with a weakness in the SMS. At every point there is a weakness that is a contributary factor of the accident and thus a domino falls - the accident event is a series of dominos falling one after another until the outcome event materialises (accident resulting in injury)

The more robust the dominos (parts of the SMS [SAFETY MANAGEMENT SYSTEM]) the less likely the domino is to fall.

The dominos falling in this scenario are in brackets

Induction Orientation [poor quality induction]
On the job/task training [none given]
risk assessment [hazards missed within the assessment or controls not implemented]
method statement SWP [items missed off the explanation of risk]
pre job brief [not given]
Supervision [poorly trained]
Engineering control [guard missing]
Audit regime [focus on systems and not work place operations]

I would suggest you take an accident within the organisation you work for and examine which barriers failed [domino's fell] as this will be a much better way of highlighting both the domino effect and weaknesses in your own SMS.

Dont forget James Reason notes that the last barrier or in this case domino is lady luck even where the probability distribution function leans to a higher propensity for the incident to happen than not.

Hope this helps

Martin

Thanks and sorry for the misunderstanding, the article is only small, as part of a monthly A4 internal newsletter. I just needed an accident/disaster to underline the importance and possible consequences.

The IT system I use at work is a nightmare and would only let me get web pages directly and I couldn’t get any of the search engines to work hence my post. I have now got it working and used the Piper Alpha as an example.

Like you pointed out, the short answer, I have to make it light and not too deep but hopefully gets the point across.

Just what I was thinking and why I used an old joke to hopefully demonstrate the point. Joke runs a bit like this: Person slips on spilt liquid and angrily picks up the knocked over container. Boss walks in and does the same, person states “I’ve just done that!” And boss fires him. Then a quick explanation of the principles and finishing with a reference to a real disaster due to a chain of events. Well that was the general idea and slightly longer of course.

Like you have identified, the Herald would also have been a good example to use but I needed the details to make the point. Anyway the article has been submitted, so job done and thank you for your replies.

Rather than use an overly simplistic model, such as the domino model, use a multi-factorial model that shows that the activity, environment and management contribute play their part in causing accidents.

Regards

You’ll get no argument from me as I fully understand and agree. However, I have to keep my word count to about 200, which as you can imagine is very restrictive and always a challenge. It has to be interesting and light, just something to keep everyone thinking. It’s just a small part of trying to improve the culture. I’m already pondering May’s newsletter subject.