Five Step Accident Prevention Process – Step 3 (continued)

Let us look more closely at the countermeasures appropriate
for each of the dominos in Step 3.

Domino 5: Major Injury or Damage (Result)

In this stage, an accident has already occurred and has caused some damage or injury. The objective of the counter-measure is to control damage and limit the extent of and effect of injuries. Line management with the technical advice of the Safety Manager has the responsibility for damage control. An example would be containment activity, first aid, evacuation, rescue, and firefighting.

Domino 4: Contact (Transfer of Energy)

Here something has gone wrong but no significant damages or injuries have occurred. The objective of counter-measures is to prevent the mishap from causing injury or damage. For
example, use of safety goggles will prevent injury even though a grinding wheel, again in line management responsibility advised by the Safety Manager, bursts (mishap) and a piece travels towards a man’s eye. Examples: Protective equipment, barriers, separation.

Domino 3: Immediate Causes (Unsafe Acts or Conditions)

These are the mistakes or errors made by operating personnel including errors that result in creation of unsafe conditions. Operating personnel could be drivers, dispatchers, maintenance personnel, instructors, or anyone else with an operational mission. The objective is to change the behavior of these personnel so they are less likely to make errors. Normally, these activities are the responsibility of the supervisor, but occasionally, for reasons of economy, efficiency, or speed, the Safety Manager may, in the name of the CEO/President directly initiate corrective action. Examples: Training, and motivation.

Domino 2: Basic Causes (System Defects)

These are the design deficiencies in various aspects of the system that increase the potential for people to make operating errors. The objective of countermeasures is to prevent or
reduce the chance of operating error. For example, faulty policies established or not established may result in reduced motivation for safety. Faulty purchasing policies (system defect) may induce purchase of faulty equipment (operating error). System defects normally exist in the form of faulty policies, procedures, and directives, or failure to prescribe the form of the procedure that should be established. Correction of systems defects is normally the responsibility of the line manager authorized to manage that particular aspect of the system.
Nevertheless, the Safety Manager may often be authorized to intervene directly in correcting a system defect in the interest of timeliness, economy, or efficiency.

The following countermeasures can be applied against each of the following system components in Domino 2.

Personnel: Improved selection process. Improved motivational climate. Improved procedures for retention and stability.

Training: Improved quality/quantity of training.

Task: Improved task design. Better human factors design. Clearer, more thorough assignment of responsibility.

Material: Improved equipment design. Improved quality and quantity.

Environment: Improved lighting. Decreased noise. Proper temperature control.

(continued in next article)

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