Page 110 - Serious Incident Prevention How to Achieve and Sustain Accident-Free Operations in Your Plant or Company

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88 Serious Incident Prevention

The types of tasks that must be executed to sustain incident-free opera-
tions are dependent upon the particular risks that must be managed. In a
health care facility, for example, we would anticipate the list of actions
needed to control risks to include critical work for addressing areas such as
toxic material control, infection control, radiation safety, asbestos manage-
ment, medical waste management, blood-borne pathogen control, fire pre-
vention, emergency preparedness, facility evacuation, elevator safety, loss
of critical utilities, and prevention of violent acts. For any type of operation,
an effective management process is needed that facilitates diligent execu-
tion of critical work required for success.
Regardless of differences in risks, the general types of causal factors
that lead to serious incidents are common to different types of facilities and
operations. Critical work must be identified for controlling each of these
causal factors to prevent deficiencies that could lead to a serious incident.
These factors, as described below, include twelve related to human per-
formance, six to equipment performance, and one to external causes. 5

Causal Factors for Serious Incidents

Human Performance:

1. Verbal communication: the spoken presentation or exchange of in-
formation
2. Written procedures and documents: the written presentation or ex-
change of information
3. Man-machine interface: the design of equipment used to communi-
cate information from the plant to a person (displays, labels, etc.)
4. Environmental conditions: physical conditions of the work area

5. Work schedule: factors that contribute to the ability of the worker to
perform his assigned task in an effective manner

6. Work practices: methods workers use to ensure safe and timely com-
pletion of task

7. Work organization/planning: the work-related tasks including plan-
ning, scoping, assignment, and schedule of the task to be performed

8. Supervisory methods: techniques used to directly control work-re-
lated tasks, in particular, a method used to direct workers in the ac-
complishment of tasks