When you look at a system approach to inspecting work areas, you must recognize that approximately 80% to 95% of all accidents are caused by human errors. This means that somewhere at some time a human being interacted with the system and, either by omission or commission, caused the hazard that resulted in an accident. There are human, material, and environmental factors that will be caused by one or more system inadequacies. Your inspections must look for these factors to identify the causes of hazards.
There are five system inadequacies that I use within the management approach to hazard inspections (Field Manual 100-14, 1999):
- Support Failure – equipment, material, or supplies not provided.
- Standard Failure – inadequate or no procedures in place.
- Training Failure – poor or no training provided.
- Management Failure – ineffective or no manager participation.
- Individual Failure – an employee that does not follow procedures.
A Support Failure could be an employee assigned to work with a corrosive chemical, but was not provided gloves because none were available. The result of this failure is likely to be exposure to the chemical and damage to the skin on the employee’s hands. The immediate cause is chemical contact with the skin. The system inadequacy is a support failure because gloves were not available.
A Standards Failure could be an employee performing work in an area with respiratory hazards and failing to notice the respirator exhalation valve is missing on the respirator he wears. In this scenario, the organization had no standard operating procedure that requires training and proper respiratory maintenance. The employee was exposed to a toxic chemical, injuring his lungs and throat. The immediate cause of injury was inhalation of the chemical, but the systemic inadequacy was a standards failure because no procedure was in place.
A Training Failure could be an employee assigned to operate a forklift that received no training beforehand. The employee operates the forklift too fast while making a turn, resulting in the forklift overturning and crushing the worker. The immediate cause was the employee driving the forklift at a high rate of speed without wearing a seatbelt. The system inadequacy was a Training Failure because the employee was not trained to operate the forklift. The training would have included the requirement to wear a seatbelt.
A Management Failure could involve a supervisor of a lawn mowing crew who does not enforce standards and ignores employees who don’t follow the rules. Thus, an employee fills a lawnmower with fuel without allowing the motor to cool. The fumes from the fuel ignite, destroying the mower and burning the worker. The immediate cause was the hot engine igniting fuel; however, the systemic inadequacy was a Management Failure because the supervisor did not enforce safety standards that required the motor to be cooled before refueling.
An Individual Failure could be an employee assigned to operate a company vehicle after he received proper training. The employee partied late the evening before and got less than two hours’ sleep. This made him fall asleep while driving, allowing the vehicle to drive off the road and overturn, injuring the employee and severely damaging the vehicle. The immediate cause of the accident was that the employee fell asleep while driving. The system inadequacy is an Individual Failure because the employee came to work the next day tired because of inadequate sleep. The system should encourage employees to take the necessary steps to come to work prepared and able to work.
Field Manual (US Army) 100-14, Risk Management Program, Washington, USA, 1999.