Substandard Acts - leading to unwanted Events
Substandard acts may lead to an accident, incident or other type of unwanted
event. These substandard acts could be done by various people at various levels in the organization; close to
the unwanted event or further upstream. By operational personnel, by management or staff.
Within the context of the simple 2 D model above we are mainly referring to acts by
operational personnel. But do not forget that the substandard act at operational level may have its roots in
lack of proper action higher up in the organization; management and supervision allowing work to be done in a
substandard way or allowing substandard conditions to exist by taking no action to correct. Staff personnel not
providing training, buying the wrong equipment, etc. or managerial personnel not making sure that staff
personnel and lower supervision do what needs to be done so operational people can carry out their work properly
and without mistakes, errors, substandard acts, etc. These very important aspects come under "job factors" under
"basic causes" indicating that, in practice, there is hardly a line between direct and basic causes of
One of the main functions of management is to control loss
To close the gap between "practice" and "theory"
Between "substandard" how it is done and "standard" how it should be done
secure or to make safe
at improper speed
safety devices inoperative
use of otherwise safe equipment
equipment in operation
following proper work instructions or rules
or improper use of protective equipment
loading or stacking
improper position for task
Substandard acts may exist because (i) there is no "standard way" if doing things,
(ii) there is not initial training on how to carry out critical tasks, (iii) there are no regular observations
or discussions to see if the work can still be done according to the procedure, (iv) the standard way is not
being updated, (v) substandard work practices are being tolerated by supervision and management, (vi)
carrying out work according to the standard way of doing things is considered "for sissies", etcetera.
Substandard acts can be found during investigation of unwanted events as
indicated in your accident or unwanted event
protocol and leading to remedial actions which may include revision of work procedures.
Observation programs may reveal substandard acts or they may be found during
normal procedures such as work permits or Last Minute Risk Assessment (LMRA).
Substandard acts may also be considered incident or
accident imaging asking the "what if" questions.