ACCIDENT CAUSATION
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ACCIDENT CAUSATION. Early Man. Factory managers reasoned that workers were hurt because —. Industrial Revolution. Number is Up. Carelessness. People Error. ACCIDENT. Cost of doing Business. Act of God. PEOPLE PROBLEM. Social Environment and Ancestry. Injury. Unsafe Act or

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Factory managers reasoned that

workers were hurt because —

Industrial Revolution

Number is Up

Carelessness

People Error

ACCIDENT

Cost of doing

Business

Act of God

PEOPLE PROBLEM


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Social Environment

and Ancestry

Injury

Unsafe Act

or

Condition

Accident

Fault of the

Person (Carelessness)

Domino Theory

1932 First Scientific Approach to Accident/Prevention - H.W. Heinrich.

“Industrial Accident Prevention”

MISTAKES OF PEOPLE


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INJURY -caused by accidents.

ACCIDENTS - caused by an unsafe act –injured person or an unsafe condition – work place.

UNSAFE ACTS/CONDITIONS - caused by careless persons or poorly designed or improperly maintained equipment.

FAULT OF PERSONS- created by social environment or acquired by ancestry.

SOCIAL ENVIRONMENT/ANCESTRY -where and how a person was raised and educated.

Heinrich’s Theorems


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Heinrich’s Theory

Corrective Action Sequence (The three “E”s)

  • Engineering

  • Education

  • Enforcement


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Modern Causation Model

  • RESULT:

  • No damage

  • or injury

  • Many fatalities

  • Major damage

OPERATINGERROR

MISHAP (POSSIBLE)


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Modern Causation

  • How accidents are caused & how to correct those causes.

  • Parallels Heinrich's to a point.

    • Injury is called RESULT, indicating it could involve damage as well as personal injury and the result can range from no damage to the very severe.

    • The word MISHAP is used rather than Accident to avoid the popular misunderstanding that an accident necessarily involves injury or damage.

    • Finally, the term OPERATING ERROR is used instead of Unsafe Act & Unsafe condition.


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Examples

Operating Errors:

  • Being in an unsafe position

  • Stacking supplies in unstable stacks

  • Poor housekeeping

  • Removing a guard


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Systems Defect

  • Revolutionized accident prevention

  • A weakness in the design or operation of a system or program


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Examples

Systems defects include:

  • Improper assignment of responsibility

  • Improper climate of motivation

  • Inadequate training and education

  • Inadequate equipment and supplies

  • Improper procedures for the selection & assignment of personnel

  • Improper allocation of funds


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Modern Causation Model

  • RESULT:

  • No damage

  • or injury

  • Many fatalities

  • Major damage

OPERATINGERRORS

MISHAP (POSSIBLE)

SYSTEM

DEFECTS

Operating Errors occur because

people make mistakes,

but more importantly,

they occur because of

SYSTEM DEFECTS


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Modern Causation Model

Managers design the Systems

COMMAND ERROR

  • RESULT:

  • No damage

  • or injury

  • Many fatalities

  • Major damage

OPERATINGERRORS

MISHAP (POSSIBLE)

SYSTEM

DEFECTS

System defects occur because of

MANAGEMENT / COMMAND ERROR


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Safety Program Defect

A defect in some aspect of the safety program that allows an avoidable error to exist.

  • Ineffective Information Collection

  • Weak Causation Analysis

  • Poor Countermeasures

  • Inadequate Implementation Procedures

  • Inadequate Control


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Safety Management Error

A weakness in the knowledge or motivation of the safety manager that permits a preventable defect in the safety program to exist.

SAFETY

MANAGEMENT

ERROR


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Modern Causation Model

SAFETY

MANAGEMENT

ERROR

SAFETY

PROGRAM

DEFECT

COMMAND

ERROR

SYSTEM

DEFECT

OPERATING

ERROR

MISHAP

RESULTS


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1

1

SERIOUS

SERIOUS

29

59

MINOR

MINOR

300

600

CLOSE CALL

CLOSE CALL

Near-Miss Relationship

  • Initial studies show for each disabling injury, there were 29 minor injuries and 300 close calls/no injury.

  • Recent studies indicate for each serious result there are 59 minor and 600 near-misses.

RECENT STUDIES

INITIAL STUDIES


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Seven Avenues

There are seven avenues through which we can initiate countermeasures. None of these areas overlap. They are:

  • Safety management error

  • Safety program defect

  • Management / Command error

  • System defect

  • Operating error

  • Mishap

  • Result


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Potential countermeasures for each modern

causation approach include:

SAFETY

MANAGEMENT

ERROR

1

TRAINING

EDUCATION

MOTIVATION

TASK DESIGN

2

3

4

5

6

7

Seven Avenues


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Potential countermeasures for each modern

causation approach include:

SAFETY

PROGRAM

DEFECT

1

3

4

5

6

7

Seven Avenues

2

REVISE INFORMATION

COLLECTION

ANALYSIS

IMPLEMENTATION


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Potential countermeasures for each modern

causation approach include:

TRAINING

EDUCATION

MOTIVATION

TASK DESIGN

1

2

4

5

6

7

Seven Avenues

3

COMMAND

ERROR


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Potential countermeasures for each modern

causation approach include:

DESIGN REVISION VIA--

- SOP

- REGULATIONS

- POLICY LETTERS

- STATEMENTS

1

2

3

5

6

7

Seven Avenues

4

SYSTEM

DEFECT


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Potential countermeasures for each modern

causation approach include:

5

ENGINEERING

TRAINING

MOTIVATION

1

2

3

4

6

7

OPERATING

ERROR

Seven Avenues


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Potential countermeasures for each modern

causation approach include:

MISHAP

6

PROTECTIVE EQUIPMENT

BARRIERS

SEPARATION

1

2

3

4

7

5

Seven Avenues


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Potential countermeasures for each modern

causation approach include:

RESULT

CONTAINMENT

FIREFIGHTING

RESCUE

EVACUATION

FIRST AID

1

2

3

4

5

6

Seven Avenues

7


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Army Systems Model

A system is simply a group of interrelated parts which, when working together as they were designed to do, accomplish a goal. Using this analogy, an installation or organization can be viewed as a system.

The elements of the Army Systems Model are:

  • Task

  • Person

  • Training

  • Environment

  • Materiel


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Army Systems Model

TASK

  • Communication Control

  • Arrangement

  • Demands on soldiers

  • Time aspects


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Army Systems Model

PERSON

  • Selection

  • Mentally

  • Physically

  • Emotionally

  • Qualified

  • Motivation

  • Positive

  • Negative

  • Retention


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Army Systems Model

TRAINING

  • Types

  • Initial

  • Update

  • Remedial

  • Targets

  • Operator

  • Supervisor

  • Management

  • Considerations

  • Quality/Quantity


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Army Systems Model

ENVIRONMENT

  • Noise

  • Weather

  • Facilities

  • Lighting

  • Ventilation


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Army Systems Model

MATERIEL

  • Supplies

  • Equipment

  • Machine Design

  • Maintenance


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SAFETY

MANAGEMENT

ERROR

SAFETY

PROGRAM

DEFECT

RESULT

MISHAP

OPERATING

ERROR

COMMAND

ERROR

Army Systems Model

Army Systems

Model

  • Task

  • Training

  • Environment

  • Materiel

  • Person

SYSTEM

DEFECT