CONTROLS IN WORK SITUATIONS REVEALED BY
ORGANISATIONAL SLIP, TRIP AND FALL ACCIDENT (STFA)
FACTORS. CONSEQUENCES FOR PREVENTION
Sylvie Leclercq
1

INRS – Working Life Department - 1 rue de Morvan, 54500 Vandoeuvre les Nancy, France

Workplace design and upkeep or human factors are frequently advanced for
explaining Occupational Slip, Trip and Fall Accidents (OSTFAs). Despite
scientific progress, these accidents are also commonly considered to be “simple”
accidents. To encourage an evolution in these perceptions, this document sets out
to orient our vision towards organisational factors, which often combine with otheraccident factors to cause movement disturbance and injury in work situations.
These factors are frequently the outcome of arbitration between production andsafety, which implies implementation of controls by employees; controls that canlead to greater employee exposure to STFA risk. We propose a model focusing onthese controls, in particular to account for the need to confront production andsafety logics within the company and to enhance the potential for appropriate
prevention action.

Introduction
The literature often advances workplace design and upkeep (Bell et al., 2008; Amandus et al.,2012), access system configuration (Leamon & Murphy, 1995) or, again, human factors (Davis,
1983; Gauchard et al., 2001) for explaining OSTFAs. Neutralisation of these factors, with theintention of securing displacements, is a first step towards preventing such accidents. However,these prevention actions frequently overlook production requirements and this is why they can
only offer a partial response to preventing all OSTFAs. Research into these accidents effectively
shows that, as in all occupational accidents, many configurations of accident-causing events
stem from arbitration between production and safety, which cannot be ignored if progress is tobe achieved in the prevention field. These arbitrations lead to controls applied under working
conditions to perform the activity, while conserving safety. Many of these controls are reflectedin employee’s movements, which are performed when performing the task. One of the mostfrequent involves walking fast to try to catch up a delay or confront an emergency. Theseobservations provide a partial explanation for operator difficulties in systematically applying
certain recommendations aimed at preventing OSTFAs; recommendations nevertheless basedon common sense, such as “Don’t rush!”
This paper firstly introduces both the need and the limits for neutralising the accident
factors closest to the injury in OSTFA genesis. It then describes arbitrations between production
and safety prompted by so-called “organisational”1 STFA factors referred to in the literature.
1

The notion of organisation is vast and the purpose here is to describe neither the features nor different
standpoints, from which it is considered (cf. Monteau, 2010 on this subject). The organisational factors
referred to in this document are those, which refer to the organisation activity undertaken by thecompany.

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Some of these arbitrations imply implementation of controls by the employee performing thetask, reflected in his/her displacements or, more generally, in his/her movements, which
increase his/her exposure to STFA risk.
Neutralising factors closest to the injury in OSTFA genesis: need and limits
In some work situations, movement disturbance factors (floor in poor condition, difficult accessto certain work areas, etc.) may exist permanently and visibly, and may expose many employees
over quite long periods. For example, this is the case of slippery floors in food processing shops.
These factors, along with "haste" or "carelessness", are frequently advanced for explaining
STFA occurrence.
Their neutralisation often involves acting on certain working conditions (installing a slipresistant floor, reconfiguring an access system, etc.) or on behaviours (e.g. instructions toemployees to be attentive to performing their displacements or to adopting a “safe”, unhurrieddisplacement, which avoids short-cuts). However, neutralisation of movement disturbancefactors is frequently accompanied by ignorance of other aspects, which are sometimes moredifficult to objectify and control, such as the urgency of the situation, fatigue or certain activity
requirements. Yet, as in all OAs, it is often a combination of factors of different type that willcause the OSTFA. For example, a clearly visible obstruction will not be taken into account by
an employee whose visual attention is absorbed by his/her task during a displacement.
On the other hand, a STFA can occur without the involvement of a permanent, visible
anomaly in the environment: an employee, late for his/her appointment, misses a step whenrunning up stairs, which are not subject to any design anomaly. Finally, many situations aretemporarily more favourable to STFA occurrence: when performing his/her activity, an
employee collides with an element in his/her environment, which obstructs his/her movement;
the employee had intended to move this element once priority work was completed.
Hence, while it is important to neutralise accident factors, which are permanent and visible
in the work environment, it is just as important to analyse the part played by this factor in amore comprehensive accident genesis. We also need to understand the behaviours adopted inwork situations; behaviours often reflecting the presence of organisational factors.

Organisational STFA factors and underlying controls
The literature includes accounts of in-depth analyses of slips, trips and other movement
disturbances conducted at various companies. The events leading to injury are therefore
embedded in the operation of the relevant company. Some events are related to arbitrations
between production and safety, to which reference was made long ago in the general
occupational accident field. For example, situations described under the terms of recovery or
momentary co-activity by Faverge (1970) reflect such arbitrations revealed when analysing
accidents in iron mines, in particular. When analysing occupational health and safety from anorganisational perspective, Monteau (2010) refers to the “known organisational risks”; one isbound to note that few of these accidentology studies are put to advantage in relation tounderstanding and preventing OSTFAs. Yet, the contribution of multiple organisational factors
has been revealed, when analysing these accidents.
Research reported in Bentley & Haslam (1998) and in Leclercq & Thouy (2004) questions
the role of work preparation in STFA occurrence. Bentley & Haslam (1998) effectively
describe the difficulties encountered in distributing mail in time during periods when there issnow and ice. Leclercq & Thouy (2004), for their part, demonstrate that several accidents
involved field operators climbing up into and down from their trucks, when checking equipment
required for various building sites during the day. This phase of their activity demanded all themore attention since instances of missing equipment were frequent.
Furthermore, the Leclercq et al. (2007) study specifically addressing STFAs sustained bytrain drivers revealed in particular problems of task allocation or attribution as well as- 74 -

recovery situations, i.e. situations in which “the normal task is interrupted by an incident andone has to recover, in other words strive to restore the usual course of work” (Faverge, 1970).
Three train drivers effectively sustained an STFA involving scenarios with similar
characteristics. These accidents occurred when inspecting the train prior to its departure. In thefirst case, the train started to brake during the operation. In the second case, the inexperienced
driver detected a brake failure he had never before encountered and did not know how to solve
and, in the third case, the driver climbed down again from the train after forgetting an inspection
point. In every case, the driver gave his full attention to the inspection to prevent the train being
delayed and, when walking, tripped on a sleeper or a plate creating an irregularity on the
ground. In the first two cases, the driver was implementing a recovery activity at the time of theaccident to make the train braking system operational. Any recovery situation introduces or
accentuates a time constraint, so the resources mobilised to make the braking system operational
as quickly as possible were partially lacking in terms of controlling displacement and effectively
caused the driver to trip.
Bentley et al. (2005) refer to a “concurrent visual task” for explaining the occurrence of
certain OSTFAs; they also emphasise that, at a given moment, the resources dedicated toperforming the task may be lacking in terms of controlling displacement.
Moreover, in many cases the presence of obstructions to displacement results from earlier orsimultaneous work performed by employees other than the one who sustains an STFA, thereby
revealing the part played by co-activity or a succession of activities in the occurrence of these
accidents. For example, an employee has to modify his/her itinerary in reaction to tools present
on his/her route; tools that are useful to workmen installing new equipment. The change initinerary may be considered a recovery activity, which is in fact intended to restore the usual
course of work by returning to the planned itinerary. Co-activity, which was historicallydescribed by Cuny (CECA, 1969), corresponds to task performance by persons pursuing
different production objectives and required to simultaneously share the same workplace.
Interim situations or those involving subcontracted work, in particular, can generate co-activity
or a succession of activities.
Finally, Bentley & Haslam (1998) showed that the “job and finish” policy implemented at
the time in the United Kingdom’s mail distribution company, which allowed employees to gohome as soon as the last mail had been distributed, could encourage employees to take risks byhurrying or taking short-cuts. These authors reported that the employees explained that theaccident risk when reading mail addresses while walking was more acceptable than the time
wasted in stopping to read the addresses.

Consequences for prevention
Working conditions (hence movement performance conditions) play a part in STFA occurrence
since they make it more or less difficult to control displacement and movement.
The organisational factors highlighted, when analysing OSTFAs, reveal employee
arbitration between production and safety in the work situation, in which he/she is exposed to
STFA risk. These arbitrations relate in particular to the organisation activity implemented by thecompany. Neutralisation of organisational factors therefore requires local and collective
management of the STFA risk to ensure both proximity to the company’s specificcharacteristics and to confront existing logics and viewpoints. Bentley & Haslam (1998)
effectively state that, depending on the employees distributing the mail, managers consider
performance a priority over safety and that the employees themselves prefer rapid performanceto safer performance of the work; their attitudes reflecting those of the management.
As in the face of all OA risks, controls are implemented to perform the task, while ensuringsafety with regard to the STFA risk, in other words while ensuring movement control. Yet, thisrisk may a priori manifest itself during any work-related movement. These are as much “jobrelated gestures” (collision when screwing because the spanner slipped) as more atypicalmovements, such as picking up an object or displacing. Controls implemented in work
situations are thus virtually permanent and the employee manages the available resources in- 75 -

order to perform his/her task, while controlling his/her movement. The resources required formovement control vary in time and with respect to the work situation. For example, Derosier etal. (2008) report situations, in which metallurgists are sometimes required to displace
themselves over template elements similar to beams. Moreover, the resources needed to performthe task as a whole are also variable. Thus, the task characteristics and requirements willcondition the resources dedicated to movement control.
Some controls implemented in work situations, which have an impact on movement control,
can be easily observed (rushing, moving round obstructions, etc.). On the other hand, revealingsome of these controls requires a very fine observation grid (distance allocated as safety margin
between foot and low-level obstruction during a displacement, supports used, etc.). Figure 1
illustrates a model of work situation understanding based on the person and his/her activity
adapted from the model developed by Vézina (2001) in relation to musculoskeletal disorders(MSDs). MSDs and OSTFAs are all outcomes of occupational risks involving movements atwork (Leclercq et al., 2013), so OSTFA prevention, which has been the subject of little research
to date, can take advantage of studies in the MSD prevention field. Transposition of this model
is a clear illustration of this.

Task requirements (motor andcognitive requirements,
urgency, etc.)

Working conditions (premises,
spaces, equipment, physicalenvironment, etc.)

Employee (age, experience, training, etc.)

Activity
Physical Mental Social
Controls

SafetyProduction

Figure 1. Model of OSTFA understanding based on the employee and his/her activity(adapted from model developed by Vezina (2001) in relation to musculoskeletal disorders)

Conclusion
Despite scientific advances in safety, OSTFAs remain commonly considered as “simple”
accidents resulting from a malfunction in a “simple” system, which might suggest that theirprevention is “simple”… To encourage an evolution in these perceptions, this document sets out
to orient our vision towards organisational factors, which often combine with other accident
factors to cause movement disturbance and injury in work situations. Whilst manifestingthemselves in an individual's movement in a work situation, these manifestations are none theless an unwanted consequence of productive organisations. STFA organisational factors reveal
the need for local and collective management of this risk and the importance of a better
understanding of movement/displacement performed in work situations, i.e. in a context
integrating in particular task requirements and working conditions.
While the organisation activity implemented by the company represents a lever for STFA
prevention, two points should be noted: on the one hand, this organisation activity is itself
constrained and, on the other hand, this lever is not unique. Maximum possible neutralisation of- 76 -

factors close to the injury in the accident genesis and risk awareness also represent major linesof prevention. Awareness of the OSTFA risk, in particular, is an essential prerequisite to any
progress in preventing these accidents. Perception of the OSTFA risk and its more or less“accepted” nature are factors, which determine both consideration of this risk at every level ofthe company and controls implemented by the operator in work situations.

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