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Are incidents most likely to kill the ones we keep classifying as ‘minor’?

This article applied a HFACS, hazardous energy, and barrier performance evaluation framework to 62 investigation reports.

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Extracts:

·   “some events … labelled as PFIs despite lacking credible fatal potential, while others, involving substantial fatal risk, remain classified as minor”

·   “Severity of an injury depends on circumstances, while potential for a fatal outcome is a property of the work system”

·   “Fatal outcomes were not explained by isolated unsafe acts or single technical failures, but by the interaction of hazardous energy, exposure conditions, barrier performance, and human-organisational context”

·   “[SIFs] are driven by different combinations of exposure, system conditions, and barrier failures, rather than by an accumulation of minor unsafe acts alone”

·   “Fatal potential exists even when no injury occurs, provided that energy transfer was fatal under slightly altered conditions”

·   “Fatal potential is most missed in events with minor or absent injury consequences, supporting the argument that realised severity does not reliably reflect escalation potential”

·   “near misses with low injury consequence are often treated as low severity events, even when the hazard exposure and barrier state indicate credible fatal potential”

·   “Injury severity is a circumstantial outcome, whereas fatal potential can be assessed more reliably by examining energy exposure and barrier status”

·   “Of the 62 analysed cases, 39 incidents (63%) were identified as misclassified […]. Among these, 25 incidents (40%) were classified as under-classified PFIs […] despite involving credible fatal potential”

·   “Under-classification occurred nearly twice as frequently as over-classification, indicating a tendency to under-recognise fatal potential in events without severe or visible injury consequences”

·   “Although these [human and organisational] factors were often mentioned descriptively in investigation reports, they were rarely linked to fatal-risk escalation in the original PFI classification”

·   “When injury is minor or absent, investigators may downgrade event significance, even where exposure conditions and barrier integrity indicate clear possibility of the fatal outcome”

·   “Under-classified PFIs were characterised by degraded, bypassed, or human-dependent preventive controls and frequent procedure–practice gaps”

·   “Human and organisational factors affect barrier integrity, and barrier integrity determines whether high-energy exposure can escalate into a fatal event”

·   “Procedure vs. practice gaps, informal workarounds, and production-driven deviations were frequently present in under-classified PFIs but seldom framed as escalation factors in original investigations”

·   “Realised injury severity should be separated from fatal potential in PFIs”

Study link: https://doi.org/10.15159/ar.26.021