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Case Studies - The Underlying Causes of Accidents

Paper mill rollerInformation on the underlying causes of accidents is important for the improvement of safety. Industries where accident rates are anomalously high and where accident rates across an industry are particularly uneven are especially amenable to study.

The British paper and board industry was a case in point. The industry had an accident rate that was higher than average for a manufacturing industry. In addition, there was disparity within the industry, with 10% of paper mills accounting for 30% of the accidents.

HSC's Paper and Board Advisory Committee recognised this problem and HSL was asked to investigate the underlying causes.

Twelve paper mills participated in the investigation, selected to provide a representative cross section of the industry with respect to accident rates, numbers of employees, product types and geographical location. HSL's risk assessment research team spent up to three days at each site. The team carried out structured interviews with a cross section of personnel, examined the documented safety management systems and observed the operations on the sites.

Analysis of the results, for each paper mill, led to three quantitative measures for:

• the adequacy of the safety management system;
• the healthiness of the safety culture; and
• the level of technological risk involved.

Variations in scores were found for all three measures with a particularly wide variation in the scores for safety culture. The first two measures were found to be strongly associated with the accident rate found at each mill. Thus mills with lower accident rates were found to have better safety management systems and safety culture.

Following this research, regional seminars were held in which management and safety representatives from the industry agreed to the target of reducing the accident rate across the industry by 50% over a three year period. HSE requested follow-up research to evaluate whether this initiative was successful in meeting its target.

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