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Work accidents investigation technique (WAIT)—part I

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ISSUE 1 2003
Article IV-2
ISSN 1443-8844 VOL
WORK ACCIDENTS INVESTIGATION TECHNIQUE
(WAIT) – PART I
CELESTE JACINTO A, B AND ELAINE ASPINWALLA †
aSchool of Engineering - Mechanical and Manufacturing Engineering,
The University of Birmingham, Edgbaston, Birmingham B15 2TT, UK
b Department of Mechanical and Industrial Engineering,

FCT/ New University of Lisbon, P-2829-516 Caparica, Portugal

ABSTRACT
Recent developments concerning the management of health and safety, combined with pressure from
new and more strict legal requirements, are posing new challenges to all those who have to investigate and
report accidents at work. This paper proposes a practical method for carrying out accident investigations in a
structured and systematic fashion, which is, nevertheless, easy to apply by “non-experts”. It was specifically
developed for application in occupational accidents and incidents (near-misses) across all sectors of
industrial activity. It allows not only the identification of active failures, influencing factors and latent
conditions, but also their classification and coding. The paper outlines the method WAIT – Work Accidents
Investigation Technique – and shows two examples of its application. The technique has been successfully
piloted on several accidents with different levels of complexity, and covering a range of different sectors of
activity. Details of the results will be presented and discussed in a forthcoming paper (Part II).

1. INTRODUCTION
Accident research, aimed at explaining causal relationships, started as far back as the late 1920s, with
the study of small but frequent accidents at work before shifting, particularly during the 1980s, to the current
sophisticated methods, which focus generally on major accidents in high-hazard and high-tech industries.
Currently, typical research fields are, for instance, nuclear power plants, aviation, chemical process and
offshore oil industries. Recent developments in the field of Health and Safety (H&S) Management Systems
(e.g.: OHSAS 18001:1999), however, combined with pressure from new and more strict legal requirements,
has prompted attention to be put onto the important role of both pro-active and reactive monitoring of H&S
performance. A direct implication is that accident research is shifting (again) towards ordinary but frequent
occupational accidents.
Until recently, there were important legal differences in what was regarded as an occupational accident
in many countries, including those in the European Union (EU). Inevitably, this posed difficulties when
trying to compare accident statistics. To overcome such problems, a European project was launched in 1990
called ESAW (European Statistics of Accidents at Work), the objective of which was to harmonise European
statistics on occupational accidents. Within the scope of this project are the systematic collection of EU-wide

† Corresponding author: Elaine Aspinwall, Senior Lecturer, School of Engineering, Mechanical and Manufacturing
Engineering, The University of Birmingham, Edgbaston, Birmingham B15 – 2TT, UK.
Tel: 0044 – 121 – 414 4249 Fax: 0044 – 121 – 414 4152 E-mail: E.Aspinwall@bham.ac.uk
comparable data on accidents at work and the establishment of a database; more details on the ESAW
methodology can be find elsewhere (e.g.: Eurostat, 1999; Eurostat, 2000; EU-OSHA, 2000). As a result of
this effort, Eurostat (European Statistics) has been able, since 1994, to make comparative statistical studies
on accidents at work occurring in the EU, although not all economic activities are yet being covered. ESAW
is, at present, running a pilot project (Phase 3) to test the feasibility of introducing eight new variables, which
aim at collecting information on the causes and circumstances of accidents (Eurostat, 2000). The reference
year for this type of data collection was 2001, to be submitted to Eurostat in 2003.

At international level, namely at the ILO (International Labour Organisation), similar changes are also
taking place. Since the 16th ICLS- International Conference of Labour Statisticians (ILO, 1998), certain
classifications/nomenclatures have been revised and several others are being reviewed or introduced.
Although there are slight differences between the ILO and the ESAW classification schemes, they are similar
and can be made such that statistical results, by country or by aggregated results, are comparable at
international level. Some of the new variables currently being tested by ESAW-Phase 3, are recommended as
optional by the 16th ICLS Resolution (ILO, 1998).

The inclusion of new variables constitutes progress towards a better understanding of accident
causation factors and thus, allow a more efficient design of preventive policies (Jørgensen, 1998a,b). On the
other hand, it might be argued that this progress, although important, could go further in understanding
accidents and their causal factors. In fact, the new variables being introduced by ESAW only account for
causes and circumstances immediately preceding the accident and more could still be done to investigate and
report other contributing factors and the systemic (underlying) causes of accidents at work. Future
developments might include, for instance, variables related to physical working conditions, human errors,
and organisational and management factors.

Attempts to go further in this direction are currently taking place in the UK, where the Health and
Safety Commission (HSC - DD, 1998) has promoted a nation-wide discussion on whether or not the
investigation of accidents at work should become compulsory for employers. At present, there is no law that
requires employers to investigate the causes of workplace accidents; such a duty is only implicit in the
current regulations, as it is in almost all other countries of the EU. The results of this public discussion were
recently published and it shows explicitly that a large majority of respondents (over 60%) supported a
change in the law through the amendment of regulations. As a consequence, the investigation of certain
occupational accidents, dangerous occurrences and diseases will, very soon, become a legal duty in the UK
(HSC – CD169, 2001). To comply with such new legal duties, safety practitioners will need guidance and
practical tools to assist them in their jobs.

In addition to the above mentioned changes, undoubtedly playing an important role in the context in
which companies operate, there have been calls for more methods and studies in several fields of accident
research literature. Among these is the work of Wagenaar and van der Schrier (1997) who argue for the need
for more reliability studies on some of the existing tools. On the other hand, the need for new methods has
been discussed, for instance, by Kristiansen et al (1999) and Guedes-Soares et al (2000), in the field of
maritime accidents, McCullough (1999) and Hill (1999), for transportation systems, and Taylor-Adams et al
(1999) in the area of clinical mishaps. In the particular field of occupational accidents, a recent study is that
of Atkins Consultants, commissioned by the British Health and Safety Executive (HSE–CRR, 2001), which
concludes the need for a new method to be applied in “root-cause” analysis.

2. GENERAL OUTLINE OF THE WAIT TECHNIQUE


WAIT stands for Work Accidents Investigation Technique. The development of the technique was
based on both theoretical and empirical foundations. This section of the paper outlines the proposed
technique, as well as its most relevant theoretical and technical aspects. WAIT was developed for use in
occupational accidents within Industry.

2.1 Theoretical foundations of the method


WAIT provides a complete toolkit for use in the investigation and analysis of occupational accidents
and near-misses. Its framework explicitly contains a method, a set of classification schemes, and a model. Of
these, the method and the associated classification schemes are the most important since they constitute the
pillars of the WAIT technique. The model, on the other hand, is the underpinning theory, and the WAIT
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philosophy follows and integrates two theoretical approaches developed by contemporary researchers of the
1990s; they are Reason (1997) and Hollnagel (1998). This section discusses how their theories have been
incorporated into WAIT.

Preventing accidents is extremely difficult without a reasonable understanding of what causes them.
Many attempts have been made to develop a theory of accident causation, but so far none has been
universally accepted; each single model presents a specific/limited view of the problem. Each model is
conceptual in nature and, as such, limits the information obtained and the range of options for prevention
(Feyer and Williamson, 1998; Raouf, 1998). In spite of this, a number of models have been better accepted
than others, and have become more widely used. Just as the loss control model of the 1960s (Bird and
Germain, 1966) has been the dominant theory in the past decades, currently, it is apparent that the most
popular and best accepted is Reason’s (1997) model of organisational accidents, illustrated in Fig.1.

In his model, Reason traces an accident sequence from the remote organisational conditions to local
workplace factors, which in turn combine with human factors, resulting in errors and violations – labeled by
him as “unsafe acts”. These, together with equipment failure and inadequate defences (safety barriers against
hazards) are the ‘proximal’ causes of accidents – i.e., these are the active failures, which generally constitute
the most immediate and visible causes of the occurrence. Some of these unsafe acts breach the working
system’s defences/barriers, often due to existing latent conditions, resulting in an event which may vary from
a near miss to a catastrophic occurrence.

Defences – safety barriers


The main
elements of
DANGER an accident
Losses
Hazards

Latent Causation

condition Unsafe Investigation


pathways Acts
The whole system
producing the
accident
Local workplace factors

Organisational factors

Figure 1 – Adapted from Reason’s (1997) model of organisational accident causation

The model outlines three levels of concern: the organisation, the workplace and the person (or team).
When reversed, following the white arrows from the top down, this model for explaining accident causation
can be used as a method for accident investigation.

WAIT follows this model of organisational accident causation, and the intrinsically linked concepts of
active failures and latent conditions, as sub-dimensions of causal factors. It also distinguishes between the
term causes, as “what made the difference”, and the term conditions, as “those factors that are always present
– both in the case where accidents occur and in the normal case where they do not” (Reason, 1997; p.236).
The five main clusters, or groups, used for classifying organisational and management conditions, were also
adopted from Reason’s work.
From Hollnagel’s (1998), and particularly from the CREAM method, the WAIT technique follows
two fundamental principles: 1)- the belief that all human erroneous actions take place in a specific context

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and that this context can be described as a combination of individual, technological and organisational
factors; and 2)- the need to make a clear distinction between what can be observed and what can be inferred
from the observations. To comply with the latter, WAIT uses the concept of error modes for characterising
the external manifestations of human erroneous actions (i.e., the observed modes of failure). In addition, this
concept integrates very well with the engineering one of failure modes, which is also used for all other
failures of a different nature; i.e. not human. In WAIT, the classification scheme of error modes was adopted
from CREAM, as well as the classification schemes for individual (person-related) factors, which include
both “cognitive” and “general” functions. These are, typically, inferred findings for explaining why the
observed actions occurred. By adopting Hollnagel’s classifications and taxonomies for human errors, the
technique not only allows a clear distinction between observation and inference, but also maintains this
distinction if accident data is stored in databases.

To summarise the above, it can be said that, in practice, the overall process itself follows Reason’s
model and evolves from the active failures to the distal latent conditions. However, at a more detailed level,
when analysing human failures, it is the framework and certain classification schemes provided by Hollnagel
that are used in WAIT for differentiating between what was actually observed (error modes) and the possible
reasons for explaining them (individual factors). These two categories are identified and analysed at different
stages of the process.

Although Reason’s and Hollnagel’s work are the main pillars of WAIT’s theoretical foundation, the
initial part of the process also integrates, explicitly, the classic deviation approach (Kjellén, 1984 a,b; and
1998). This concept is used to search for all active failures and is embedded in the Eurostat (1999; 2000)
classification of the variable “deviation”, which is also used in the technique.

Finally, WAIT also integrates the classic tree technique, although the construction of the tree is not
immediately “visible”; there is no diagram, but a table instead. The branches of the tree are obtained by
subdividing each row, when progressing from one step to the next. This feature is shown in the examples
provided.

2.2 The WAIT process


The method has nine sequential steps grouped into two main stages. The first comprises a simplified
investigation, which focuses on the analysis of immediate causes and circumstances and covers legal
reporting requirements. In this first stage, WAIT makes use of certain harmonised European variables,
including some of the new ones being currently introduced. The second stage is an “in-depth” analysis –
frequently called a full investigation – in which other possible weaknesses and conditions within the
organisation are also identified and analysed. This second stage goes beyond the current legal duties; it is
intended to provide companies with a structured tool for identifying opportunities for improving their safety
practices and policies, regardless of whether or not they have a formal safety management system. The
ability to use the WAIT technique even in companies without a formal safety management system is
considered one of the strengths of the method. In fact, the organisational and management conditions are
firstly analysed in terms of five broad clusters of general management functions, or sub-systems (see Reason
1997, p.122). The advantage of this broad grouping is that all companies, regardless of size, activity and
level of formality, will have these functions. At the core of these groups, and underlying all of them, is the
issue of organisational culture. Thus, this generic classification approach allows organisational and
management conditions to be identified and coded in all companies. Only after this, will the potential
weaknesses encountered be linked to the company’s own safety management system. If a formal system does
not exist, WAIT makes use of a standard model for illustrating that particular step. The model adopted was
that specified in the OHSAS 18001(1999).

The technique makes a clear distinction between observable events (or facts) and inferred findings.
The first stage – the basic investigation – generally deals with the observable elements of the system and thus
presents little opportunity for bias. It also allows the process to be carried out by a single person if necessary,
which is the current practice in most companies. In contrast, during the second stage – the in-depth analysis –
the use of a team is highly recommended since it will be necessary to make assumptions and deductions,
regarding possible cause-effect relationships at a higher level of the organisation.

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The process
The technique, like its main underlying model, outlines three levels of concern: the organisation, the
workplace and the person. It is a sequential and quite straightforward process; it evolves from the active
failures associated with the chain of events leading to the accident, through to the latent organisational
conditions behind them. In between these two levels, the technique directs investigators to scrutinise other
contributing elements within the working environment, the person, and the job. These are called,
respectively, influencing factors, individual factors and job factors. All these main levels are divided into
sub-categories (or groups) which have their own classification and coding schemes.

The WAIT process is summarised in the flow chart of Fig.2. Although the method is basically a
sequential one, certain stages contain loops to ensure that cause-effect relationships are logical, coherent and
complete, and stop-rules to show the end of the basic investigation and the start of the in-depth analysis.

Collect information through direct observation and by interviewing all


people involved in the occurrence, whether or not they were injured.
These people will provide their own description of the accident
Step 1 sequence and their part in the events. At the end of the interview,
Collecting information distribute to each person a list of standa rd questions, which may help
to draw attention to other less obvious facts, and disclose further
relevant information. Standard questionnaire is provided.

Decide which events constituted “active failures” by systematically


searching through all the following possible categories: HUM
Step 2 (humans), E&B (equip. and buildings), HAZ (hazards), LOR (living
Identifying all active organisms), and NAT (natural phenomena).
failures
To help with the words, you may find it useful to use the checklists
provided (classification schemes for all 5 categories).
Display all active failures in a table (column 1 of the table) in
chronological order – register each single event in one row.

For each active failure, search for possible “influencing factors”, which
Step 3 might have facilitated or triggered the failure under consideration. To
Establishing the applicable do this, use the answers to the questionnaire in step 1, combined with
influencing factors the classification lists provided.
If more than one factor is encountered, subdivide the particular row –
displaying the findings in column 2.

Review the analysis and Repeat the search for each row of column 1 (each active failure).
gather more information
if necessary
Compare all findings of columns 1+2 with relevant risk assessments.
Risk Assessment is a legal and fundamental duty. Check if the
Step 4 hazards, human failures, … and risks involved in that particular
Comparing findings occurrence had been actually considered in the risk assessment(s). If
with relevant Risk RA exists and all risks were considered, ask why it failed to prevent
Assessment(s) - RA that particular case. Establish whether or not the applicable RA is
good enough or needs improvement.

The record of the risk assessment itself, may draw your attention to
other possible problems, either active failures or influences, that were
not mentioned in the previous steps.

Yes
Other failures or Step 4 will help the investigator to determine if the previous ones are
factors could be
identified as complete and whether the relationships encountered are logical,
probable ? coherent and consistent. If no more relationships are found, this is the
END of the basic investigation, and an in-depth analysis can be
performed whenever necessary. In-depth analysis goes beyond
official reporting duties and companies should have a criterion for
No deciding which cases need a full or in-depth investigation.

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If an in-depth investigation is needed
For each new row of column 2, search for human factors - within the
individual(s) and the job, or working system - which are believed to
Step 5 have contributed to the active failures and their influencing factors.
Analysing individual & Note: the number of initial rows will probably have increased in column
job factors 2, by adding the context in which active failures occurred. Consider
each one of them. To help the search, use the classification scheme
provided for individual and job factors.
Include new factor(s) in If more than one factor is found, then, subdivide each row again, and
column 2 – and review display the results in column 3.
the analysis from step 4

For each new row of column 3, search for organisational and


Step 6 management factors or conditions which may have facilitated, or may
Analysing organisational & explain, why the previous events occurred. Use the classification
management conditions scheme provided, to help identify such weaknesses in a systematic
manner.
Display the results in column 4.

For each new row obtained in column 4, verify if any other “influencing
Yes More factor” is necessary to help explain cause-effect relationships.
Influencing factors
were identified? The in-depth analysis only STOPS when no more cause -effect
relationships can be established. The table is now complete.

On a separate form, link the general management problems


No encountered to your own H&S Management System. Notice that a
particular problem, such as, “inadequate management of contractors”,
Step 7 may have to be linked to different elements of the system (e.g.:
Linking findings to H&S planning, or implementation).
Management System If your company does not have a formal system, this is a good
opportunity for prioritising needs in terms of implementing one. In
WAIT, a standard OH&S Management System (the OHSAS
18001:1999) will be used as a model for establishing the links.

Based on the results of the analysis (basic + in-depth), make a list of


Step 8 recommendations and propose a plan of action. Whenever possible,
Making include the following information:
recommendations Recommended action / responsibility for executing / time expected for
completion / rough estimation of cost / expected benefits/ priority.

Re-analyse the case from a different point of view – this time searching
for the existence of “positive influencing factors”. To do this, re-analyse
Step 9 all information and, if necessary, re -interview people under this new
Searching for positive perspective.
influencing factors In addition, highlight the benefits of “good practice” (if it was present) so
that other co-workers can appreciate successful behaviours and realise
their importance.

If positive influences or circumstances are found, establish whether


Any positive they are merely a “random” coincidence, or if they are of a
Influencing factors “controllable” nature – thus providing clues for new or better
were identified? preventive / protective measures. If so, review step 8 and include
them in the “recommendations”.

No (or only random – not possible to control)


END

Figure 2 – Flowchart of the WAIT process

Finally, it should be noted that an accident analysis looks for acceptable or plausible causes, rather
than the “absolute true” (Hollnagel, 1998), and a limitation of any analysis is that the classification schemes
and the methods used, whichever they are, determine what the set of plausible causes can be, and thus,
restrict the search. This is also why the issue of “validity” is always so difficult to assess. In practice, an
analytical method should use a classification scheme that has been adjusted to take into account the specific

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characteristics of the domain. Naturally WAIT is no exception to this limitation, and the technique’s
classification systems are only suitable for use in industrial environments.

The process illustrated in Fig.2, together with the classification systems, constitute the fundamental
pillars of WAIT. In addition to this, the method suggests a structure for the interviews, and contains a
standard questionnaire for collecting information on possible influencing and individual factors.

Other features of interest


One particular feature of WAIT is that it directs investigators to explore positive attributes of
accidents, and to learn lessons from successful events and behaviours, as much as from mishaps. These are
called positive influencing factors and the formal definition is included in a User’s Manual of the technique.
The idea is not new (see Rundmo, 2000), but WAIT is the first technique to address this issue explicitly and
in a systematic and formal manner. The aim of this step is twofold, namely:

1. to disclose other kinds of accidental factors (unplanned / unexpected / deviation from normal)
which, by “mere chance” had a positive impact and could provide clues for new preventive
measures, and

2. to identify good practice and highlight their benefits, so that other co-workers can appreciate
successful behaviours and realise their importance.

It is believed that both aspects can bring a positive contribution to post-accident analysis. Besides,
appraising good behaviours and attitudes will help people to feel appreciated, and is an incentive to improve
safety.

In addition to the above, other noteworthy features in WAIT are the following:

• It has been recognised (e.g.: Hale, 2001) that not all accidents offer the same opportunity for
learning, and that there is a need for using time and resources efficiently. For this purpose, WAIT
provides two levels for carrying out investigations: simplified and in-depth.
• WAIT advocates the investigation of certain near-misses in the same structured manner as
accidents since they are frequently a precious source of information and learning. Their systematic
reporting and analysis have been increasingly considered an important and integral part of a safety
management system in industrial facilities (Jones et al, 1999).

3. CURRENT WORK AND RESULTS


The WAIT technique was firstly tested in a pilot run covering 5 industrial companies, from different
sectors of activity, arranged through the British Health and Safety Executive. This covered 17 cases which
have been analysed on site – all of them being relatively recent accidents in which the victims and other
relevant persons could be re-interviewed to test the usefulness of the questionnaire. About a third of these
accidents were serious cases reported to the authorities, whereas the others were simple cases of very low
gravity. The initial results appeared to be promising, and both the technique and its classification systems
were able to cover all situations.

In every case, even the simplest one, the technique disclosed several weaknesses at the organisational
and management level. Interestingly, some of the problems identified were not even known – or had not been
identified – by the company concerned. Management weaknesses encountered in the pilot run covered a
variety of areas and functions, although the most frequent were problems associated with poor risk
assessments, poor supervision and insufficient training (or lack of identification of training requirements).
Tables 1 to 4 show two examples of the WAIT analysis. The first was a relatively complex fatal accident,
and the analysis was based solely on the vast amount of documentation available. In this case, which is
merely illustrative, many questions remained unanswered, and this served to show the potential and
completeness of the technique. The second case is part of the pilot run and was quite a common and simple
accident, which was re-investigated using WAIT, following its complete process from the beginning. For the
sake of simplicity, the coding of information is shown only in the second case.

The pilot run showed that - in general terms - the target users found the method useful and relatively
easy to use, but also considered the coding of information as time consuming and unnecessary. It should be

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noted, however, that all these companies were either small or medium sized enterprises (SMEs) who do not
have a database for recording their accidents – all of them use paper records only. In addition, only 3 of the
firms use accident data to produce monthly reports and simple statistics.

This first trial also unveiled some pitfalls of WAIT, particularly at the level of certain classification
schemes, which needed to be regrouped and rearranged in order to ensure that the factors listed have a
common meaning for different users.

After refinement of the technique, a second and larger experimental run was carried out, to allow a
more comprehensive testing of its performance, in terms of coverage and applicability to other real situations
and various conditions. Another 11 organisations were involved in the second trial, this time covering not
only SMEs, but also a few large firms. In both trials the procedure was the same: all were real accidents and
were investigated on site. The use of the European harmonised variables was also addressed. In addition, two
specific validation studies were designed to assess, as far as reasonably possible, the validity and reliability
of WAIT. The first is completed, and the latter (an inter-analysts reliability study) is currently being carried
out.

The overall results are interesting and certain findings appear to be not only logical, but compatible
with what is known from other types of accidents. All results will be presented and discussed in a separate
paper (Part II).

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Table 1 – Description of accident (fatal accident on a ship-building yard)

Case No: ---- Company X 1997 08:25 h Ship-building yard - Manufacture of transport equipment – NACE code 35
Demonstrative purposes Large size
only
The task to be performed consisted of positioning a steel beam (12m x 332mm x12mm) on a working bench, so that another beam of the same length, 135mm
wide and 18mm thick, could be welded to the first. The steel beams were being handled by an overhead travelling crane (lifting capacity of 10 tons).
A worker whose task was to handle the controls (exclusively) normally operated the crane from the control post (cabin), slightly elevated in order to provide a
general view of the area. However, on this particular day, it was being done by remote control by two workers, who shall be referred to as workers A and B.
After positioning the two beams, it was realised that it was necessary to adjust one of them by 300mm, as they were not properly aligned. In order to level the
two beams, worker B was directing worker A to this effect.
When the two beams were properly aligned, worker B instructed his colleague to stop the crane. However, when operator A tried to do so, the commands did not
respond and the crane continued its normal motion. It was then that he noticed three other colleagues (welders) working near by and in the path of the running
crane. To avoid the worst (so he thought), he immediately dropped one of the ends of the beam in the hope that the resulting friction would eventually stop it.
Actually, the beam stopped, but not the crane, which by its continued motion caused a great deal of stress on the beam, to the point of snapping it under the
strain. The fixed part flew over the head of operator A, causing no harm. The other end, however, rotated in a clockwise direction hitting two other workers and
knocking them down. The first one (welder C) was injured in his foot and the second (welder D) on his torso. When welder D tried to get up, the beam swung
back and hit him again, this time on his head, killing him. Realising what was happening, worker B ran to the controls and pushed the emergency button, thus
stopping the crane. After this fatal accident, the overhead crane was never again operated by remote control.
Findings of the official inquiry (inspectors):
It was established that both workers (A & B) had been reassigned from others duties just 2 days before the accident. Furthermore, the fact that worker A did not
know how to use the emergency button - as he should have done in order to stop the crane movement - was a clear indication that he lacked the appropriate
training and skills to manage the equipment. When the remote control commands were examined, one of the handlers, showed a small deficiency (mechanical
wearing). In his statement, worker A declared that, according to other colleagues, the crane had caused similar problems previously; namely not responding to
the remote control, which was the immediate cause of this accident. Hence the instructions, from management, that the equipment would only be handled from
the appropriate control cabin. Applicable legislation requires that workers should always be subject to appropriate training prior to initiating their duties, as well
as an obligation by management to maintain and service all equipment. It was concluded that there had been negligence from management by failing to apply
the existing internal rules and official regulations. Had the existing safety procedures been observed, the accident would not have happened.
OBS: this happened in a very large company, with a formal safety management system and having a long tradition in, and good reputation for, safety.
Table 2 – Results of WAIT analysis (fatal accident on a ship-building yard)

10
11
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Table 3 – Description of accident (example – case 014)

Case No: 014 Company D 2002-03-08 12:55 h MANUFACTURE OF MACHINERY - 29


Medium size
Production worker DH was cleaning silt out of a pit, in the steam clean area. To help himself out of the pit he grabbed the barrier (rail),
which became detached from the fixing bolts and subsequently fell on him. DH was struck on his forehead. Resulted in a bump and a
superficial scratch. No treatment necessary. No days lost.
Worst possible consequence: brain damage or even death by drowning if he had fallen in the pit, unconscious, with his head below water.
Additional notes: this pit falls under the definition of “confined space”. A second person was working near by, outside the pit.
Conclusions & recommendations of original report / record (transcription):
The holes in the base plate of the barrier have a slightly bigger diameter than the nuts fitted to the floor bolts – hence barrier
detachment (barrier was loose).
Recommendations: barrier base must be fixed to the floor, using 4 bolts with adequate washers, instead of the existing 2 bolts. A second
barrier is also loose and requires attention.

13
Table 4 – Results of WAIT analysis (example – case 014)

14
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4. CONCLUSIONS
This paper has discussed some of the relevant changes taking place, at both European and
International levels, regarding the registration and recording of occupational accidents. As a result, it is felt
that new – or adapted – methods are needed for the investigation and analysis of accidents at work, and a
method has been proposed for use in this particular field of application.

The WAIT technique – Work Accidents Investigation Technique – was described in some detail and
commented upon. It integrates more than one theory and method and recognises that accidents offer different
learning opportunities; thus, it allows investigations to be carried out in two stages: the first being a
simplified investigation process, and the second an in-depth analysis accounting for human factors and
organisational/management conditions. WAIT is a straightforward process, relatively simple to apply and it
encompasses certain innovative aspects. Of these, two features are apparently of particular interest. On the
one hand the method’s classification systems include certain European variables, which are currently being
tested – by the Eurostat – in a pilot run with the purpose of collecting more data for the production of
harmonised European statistics. On the other hand, WAIT directs investigators to search for “positive
influencing factors”, as another potentially important source of learning the right lessons and disclosing
useful clues for improving preventive and/or protective strategies.

Although it is early days, the results from the two trials in industry, as well as preliminary validation
studies, showed the technique to be promising. Results of experimental work will be thoroughly presented
and discussed in a future paper (Part II).

ACKNOWLEDGEMENTS
This paper is part of a research programme leading to a PhD thesis, which is being co-financed by
“Universidade Nova de Lisboa” and “Fundação para a Ciência e a Tecnologia” (PRAXIS XXI –
SFRH/BD/817/2000), Portugal. The research programme is being carried out at the School of Engineering -
Mechanical and Manufacturing Engineering, University of Birmingham, UK. The authors are grateful to all
16 organisations who participated in the testing and validation of WAIT.

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