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chris42  
#1 Posted : 18 July 2022 11:23:54(UTC)
Rank: Super forum user
chris42

I don’t normally ask questions regarding this, and to be clear this has nothing to do with RIDDOR. There is no particular accident, just reviewing accident going back over time.

My question - Are there some accident that do not have a root cause?

If there is a specific task undertaken and there is a definite injury, in my view it makes it an accident. However, what if the task is one that has been done a thousand times before and done by lots of people.

To give an idea of what I was thinking about, something like moving a wheelbarrow full of things or hitting something with a sledgehammer, both strenuous but should not be an issue to do. However, what would be the root cause if someone say tore a muscle in a bicep or similar. There are obviously potential alternatives, ie dumper truck or concrete breaker etc. However, there should not be an issue using a barrow or sledgehammer they are used widely.

So, can you have an accident without a root cause?

Interested in others thoughts.

Chris

peter gotch  
#2 Posted : 18 July 2022 12:37:28(UTC)
Rank: Super forum user
peter gotch

Hi Chris - I am not sure that the qualifying word "root" is neeeded for your question.

There will be some events that (looking back and then forwards, ie. so as to avoid hindsight bias) were not and could not be foreseen - no cause. A "freak" accident.

Then far more which do have a cause but where a risk assessment might reasonably conclude that doing the work by some other method is not reasonably practicable.

BUT.....if the worst comes to pass and the incident ends up in a UK court, the onus of proof as to what was or was not reasonably practicable rests with the primary duty holder, usually the person's employer,

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chris42 on 18/07/2022(UTC)
Kate  
#3 Posted : 18 July 2022 12:59:34(UTC)
Rank: Super forum user
Kate

If you assume that we live in a world governed by the laws of science (or alternatively even by the laws of magic or by astrology - which  are equally based on cause and effect), then everything since the big bang has  causes, even if you don't know what those causes were or if knowing what they were doesn't help you prevent recurrence.

I'm certain there will be accidents where you can't determine a cause or determining it isn't helpful in any way.

thanks 1 user thanked Kate for this useful post.
chris42 on 18/07/2022(UTC)
Holliday42333  
#4 Posted : 18 July 2022 13:43:14(UTC)
Rank: Super forum user
Holliday42333

As Kate has alluded to, there will always be a root cause.

However I have done plenty of incident investigations over the years were an assignable root cause has not been concluded.

Usually because the residual risk that casused the incident was known and accepted  and/or because the root cause has no appropriate remedial action.  In the RCA methodology I use, all the branches of the chart would come to a justifyable stop.

Managers hate this scenario at the review stage of the investigation as for years the management of zero mantra has been that all incidents must have a cause and remedial actions put in place to prevent the root cause and therefore the incident.

thanks 2 users thanked Holliday42333 for this useful post.
Kate on 18/07/2022(UTC), chris42 on 18/07/2022(UTC)
chris42  
#5 Posted : 18 July 2022 15:45:51(UTC)
Rank: Super forum user
chris42

Thanks all, I think while reviewing old accidents I started to think too deeply and got myself tied up in a knot. Yes, I’m ok with the concept of a freak accident and that you could not plot the actions and interactions of every atom in the universe to be able to accurately predict the future to avoid all accidents.

I admit I’m loving the idea of the root cause of some accidents being a result of the big bang or evolution. It has amused me on and off all afternoon. After all if the big bang hadn’t happened we wouldn’t be having this conversation (or would we).

I suspect these types of incidents are few and far between, and not sure I have ever come across one that didn’t have some sort of cause(s) before. Perhaps I have been lucky.

Chris

thanks 1 user thanked chris42 for this useful post.
peter gotch on 19/07/2022(UTC)
peter gotch  
#6 Posted : 19 July 2022 11:19:36(UTC)
Rank: Super forum user
peter gotch

Morning Chris

Perhaps I have been a little less "lucky" with my investigations!

In the course of 9 months, I investigated three accidents at tenement refurbishment projects in the same post code.

1. Apprentice roofer fell through cupola roof light and landed at the bottom of the stairwell - about 20m. 5 stitches to the front of his head and five to the back.

2. Man fell from stairhead scaffold and landed at the bottom of the stairwell - about 18m. Tore ligaments in his leg.

3. Plumber had a single floor board up in a flat at towards the end of the project. Fell maximum of 340mm but due to a combination of things happening stumbling (with a clear cause-effect chain along the way) died in hospital 10 days later.

In each case, the immediate cause was obvious - slip, trip or fall on the level/from height.

In Nos 1 and 2 a root cause analysis would come up with lots of underlying causes that could and should have been identified to introduce actions that, if they had been taken would have prevented the accident and thence, injury.

I doubt that these actions would include checking that the staircase bannisters were in good condition (though that should have been done for OTHER reasons) - two men's injuries were almost certainly substantially reduced as each bounced off the bannister on their way down.

But, as for Number 3, absolutely no point in doing an RCA - Short of demolishing the building and starting again, you have to remove that single floorboard to do a task required in the refurbishment and I challenge anyone to tell me that it would be reasonably practicable to erect double guard-rails and toe-boards to protect against someone falling 340mm when the floorboard is going to be out of position for an hour or two.

....and even on a new build there are going to be occasions when a floor board is not in position EXCEPT if the most forward Modern Method of Construction ('MMC') are in place, so that all the services are fitted in the factory and then the complete room ("module") is slotted into place, but......introducing other risks, usually inclusive of crane operations. But the designers would probably not be thinking about the remote risk of falling 340mm when choosing an MMC option.

P

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