PROCESS SAFETY

(CEV654)

Chp. 3:
THEORIES OF ACCIDENT
CAUSATION
HAMIZURA BT HASSAN
FACULTY OF CHEMICAL ENGINEERING
UiTM PULAU PINANG
 Course Outcome
• Identify the basic principles of process hazard analysis and
safety related to the chemical engineering / environmental issues
(A4).
• Explain the issues and solutions in managing the chemical
engineering / environment using the basic principles of process
hazard analysis and safety (C6).
Course Learning Outcome
The student should be able to :
• Define accidents and incidents
• Describe theories of accident causations
• Identify root causes and immediate causes of accidents
• Explain causes of loss containment
What Have you learned
so far……..???

• Hazard
• Risk
• Categories of Hazard
• Safety versus Health
• Acute versus Chronic
• Engineers and Safety
Incident versus Accident

• Incident: all undesired circumstances that have the

potential to cause accidents.
• Accident: a sequence of events that produce
unintended injury, damage to property or the
environment, production losses, or increased
liabilities.
• Accident refers to the event, not the results of the
event.
Near Miss……..
• an unplanned event that did
not result in injury, illness, or
damage – but had the
potential to do so.
• another term for this event:
“close call”
Accident Pyramids

1
1 Major
Accident
Major
Injury 10
Minor
29 Accident
Minor 30
Injury
Property Damage
300 Accidents
Incidents
(near miss)
600
Near miss

H.W. Heinrich (1931) Frank E. Bird Jr (1969)

Key Questions
• Why do accidents occur?
• How do accidents occur?
• What must we do to keep them from
happening?
Why do accidents occur?

• We choose to handle dangerous processes,

materials, energies
• To make a living
• To provide society with desirable products
• As long as we choose to handle them, a potential
for loss events exist.

Things can be done to reduce their likelihood

and severity to negligible or tolerable levels.
How do accidents occur?
• There are several theories that attempt
to explain the occurrence of accidents.
• Most widely used theories of accident
causation:
 Domino theory
 Human factors theory
 Accident/incident theory
 Sociotechnical system framework
Heinrich’s Domino Theory
• Herbert W. Heinrich, an early pioneer of accident
prevention and industrial safety.
• He studied 75,000 reports of accidents for
insurance claims and concluded:
 88% of industrial accidents are caused
by unsafe acts committed by workers
 10% of industrial accidents
are caused by unsafe
conditions
 2% of industrial accidents
are unavoidable.
Heinrich’s Domino Theory
 State that accidents results from chain of sequential
events, metaphorically like a line of dominoes falling
over.
 When one of the dominoes fall, it trigger the next one
and the next.
 But removing a key factor (such as unsafe condition or
unsafe act) prevent the start of the chain reaction.
 Heinrich outlined five factors in the sequence of events
leading up to an accident.
 There are ancestry and social environment, fault of
person, unsafe act and/or unsafe condition, accident
and injury.
 5 factors in the sequence of
events leading up to an accident

Social Fault of Unsafe Act

Environment Person or Accident Injury
and Ancestry (Carelessness) Condition
Heinrich’s Domino Theory
• Ancestry and social environment
• Heinrich explains that undesirable personality traits such
as stubbornness, greed, and recklessness can be “passed
along through inheritance” or develop from a person’s
social environment contribute to Faults of Person.

• Fault of a person
• Heinrich explains that inborn or obtained character
flaws such as bad temper, inconsiderateness, ignorance,
and recklessness contribute to accident causation.
• According to Heinrich, natural or environmental flaws in
the worker’s family or life cause the secondary personal
defects, which are themselves contribute to Unsafe Acts,
or and the existence of Unsafe conditions.
Heinrich’s Domino Theory
• Unsafe Act and/or Unsafe Condition
• Heinrich felt that unsafe acts and unsafe conditions were
the central factor in preventing incident and easiest
causation factor to remedy, a process which he likened
to lifting one of the dominoes out of the line. These
combining factors (1, 2, and 3) cause accidents.

• Accident
Typically, accidents that result in injury are caused by falls
and the impact of moving objects.

• Injury
Typical injuries resulting from accidents include
laceration and fractures
 Heinrich’s theory has two
central points:

• Injuries are caused by the action of preceding

factors

• Removal of the central factor (unsafe

acts/hazardous conditions) negates the action
of the preceding factors and, in so doing,
prevents accidents and injuries.
Removal of unsafe acts/unsafe
conditions prevents the accident

Injury

Accident

Unsafe act/unsafe condition

Fault of a person

Ancestry and social environment

Heinrich’s Axiom of Industrial
Safety
• Injuries result from a complete series of factors,
one of which is the accident itself
• An accident can occur as a result of unsafe act
and/or unsafe conditions
• Most accidents are the result of unsafe behaviour
by people
• An unsafe act or an unsafe conditions does not
immediately result in an accident/injury;
Heinrich’s Axiom of Industrial
Safety
• The reasons why people commit unsafe acts can
serve as helpful guides in selecting corrective
actions.
• The severity of an accident is largely fortuitous and
the factors that cause it are largely preventable.
• The prevention techniques are analogous with the
best quality and productivity techniques.
Heinrich’s Axiom of Industrial
Safety
• Management should assume responsibility for
safety because it is in the best position to get
results.
• The supervisor is the key person in the prevention
of industrial accidents.
• In addition to the direct costs of an accident (i.e.
compensation, liability claims, medical costs, and
hospital expenses) there are also hidden or indirect
costs.
Human Factors Theory

Attributes accidents to a chain of events that

were ultimately the result of human error.

Overload

Inappropriate Inappropriate
activities response
Overload
• An imbalance between a person’s capacity at any
given time and the load that a person is carrying in
a given state.
• A person’s capacity is the
product of such factors
as his/her ability,
training, state of mind,
fatigue, stress, and
physical conditions.
Overload

• Added burden resulting

from
 Environmental factors
(noise, distractions, etc.);
 Situational factors (level of
risks, unclear instructions,
etc.); and
 Internal factors (personal
problems, emotional stress,
worry, etc.)
Inappropriate Response
• How a person responds in a given situation can
cause or prevent an accident.
• Inappropriate response include:
 A person detects a hazardous condition but does nothing
to correct it;
 A person removes a safeguard from a machine in an
effort to increase output; or
 A person disregards an established safety procedure
• Such responses can lead to accidents.
 Inappropriate Activities

• Examples of inappropriate
activities include:
 A person undertaking a task he or
she doesn’t know how to do
(performing tasks without requisite
training)
 A person misjudging the degree of
risk involved in a given task and
proceeding based on that
misjudgment.
 Human Factors
Theory

Overload Inappropriate Inappropriate

Response Activities
Environmental
factors Performing task
Internal Factors Detecting hazard but
not correcting it without the
Situational Factors requisite training
Removing safeguards
from machines & Misjudging the
equipment degree of risk
Ignoring safety involved with a given
tasks
Accident/Incident Theory
• Extension of the human factors theory, developed
by Dan Petersen.
• Introduced such new elements as ergonomic traps,
the decision to err, and system failure.
• In this model, overload, ergonomic traps and
decision to err lead to human error.
• The system failure is an important contribution of
Petersen’s theory.
Some ways that a system fails -
Petersen
• Management does not establish a comprehensive
safety policy.
• Responsibility and authority with regard to safety
are not clearly defined.
• Safety procedures such as measurement,
inspection, correction and investigation are
ignored or given insufficient attention.
• Employees do not receive proper orientation.
• Employees are not given sufficient safety training.
 Petersen’s Accident/Incident Theory

Overload Ergonomics Decisions to

Traps err
Pressure
Fatigue Incompatible Misjudgment of
Motivation workstation the risk
Drugs

Process Safety - CPE615

Incompatible Unconscious
Alcohol expectation desire to err
Worry

Human Error

System failure

Policy Accident
Responsibility
Training
Inspection
Corrections
Injury/ Damage
Standards
The sociotechnical framework
• Every fault in an incident scenario will have been
affected by root causes.
• Failures in large industrial system cannot be

Process Safety - CPE615

considered solely in technical terms.
• The sociotechnical system approach emphasises
the individual, organisational, management and
technical aspects which affect a system’s
performance.
The sociotechnical framework
• The entire human and technical system and its
interactions contribute towards safe operation of a
plant.

• The sociotechnical approach emphasises the individual,

organisational, management and technical aspects

Hasnora Jafri
FKK UiTM
which affect a system's performance.

• Both the non-technical and technical aspects are

influenced by the organisational structure, the forms of
management control and the way in which operators
perform their tasks.

• Subsystem within a sociotechnical system

The sociotechnical framework
The sociotechnical framework
• External systems are influences outside the
boundary of the system which affect it but are not
significantly affected by the system itself.

• System climate includes influences such as

business factors corporate culture, safety culture
and technical know-how which exist within the
environment of the company.
The sociotechnical framework
• Organisation and Management
Provides the scope for decision-making and problem-
solving within a company.

It is the structure within which processes and roles are

defined and allocated to meet the functional
requirement of the plant.

This includes general conditions of work, relationships

formally defined by organisational charts and job
description.

Resources provision should be sufficient and

adequately allocated to the various functions such as
finance, expertise, information, equipment and
emergency needs.
The sociotechnical framework
• Site and Plant Facilities address
• the plant design and its realisation,
• the layout of the site,
• safety issues of current engineering projects and
• consideration of the storage and transport of materials.

• Engineering Integrity refers to

• the reliability and availability of the plant - that is, the
hardware, machinery and its associated control systems
• which need to be assured beginning from the design of
the plant and continue through to fabrication,
installation, operation and maintenance.
The sociotechnical framework
Management Control
• Refers more specifically to the management of safety
for this particular study.
• It includes factors such as the setting of standards,
performance indicators, priorities and targets,
maintaining and-improving those standard
• Decision-making functions, allocations of resources are
examples of activities in this subsystem.
• Supervisory is a key factor
The sociotechnical framework
• Communication and Information
Refers to the dissemination and processing of
information vital to the safe functioning of the
system.
These include the provision of operating procedures,
plant logs, permit-to-work systems and also emergency
response information.
Toxicity data, material safety data sheets and operating
parameters are elements to be noted when reviewing
this subsystem.
Communication systems must be effective.
The sociotechnical framework
Procedures and Practices
Provide clear instructions for conducting
activities in a safe manner in the-to-day
running of the operations.
 Rigorous and accurate procedures are the
basis for safe and reliable operation.
 Proper dissemination and training in use is
important in promoting good working practices.
The sociotechnical framework
Working Environment
• Refers to the workplace and the conditions within
it.
• How the operators work and go about their
task are considered.
• It is helpful to consider features such as
welfare, the safety culture prevailing and the
availability of immediate supervision and
support.
The sociotechnical framework
Operator Performance
• Refers to the activities in which shop-floor
employees are involved.
• These are the individuals who have direct
interaction with the plant - operating staff,
supervisors, fitters and maintenance staff.
• It encompasses all aspects which directly affects
staff performance including level of training and
skills, workplace design, psychological and
physiological effects.
Root Causes of Incidents – the
Sociotechnical Framework
• Refers to the activities in which shop-floor
employees are involved.
• These are the individuals who have direct
interaction with the plant - operating staff,
supervisors, fitters and maintenance staff.
• It encompasses all aspects which directly affects
staff performance including level of training and
skills, workplace design, psychological and
physiological effects.
System climate Technical understanding
Legislation/regulations
Political climate/pressure groups
Economic climate/business factors
Business focus
Corporate culture, Safety culture
Organisation and Decision-making hierarchy
management Commitment to safety
Interaction with
internal/external systems
Resource provisions
Production resources
Site and facilities Site and its layout
Engineering and process
design
Commissioning and
realisation of plant
Detailed engineering
Transport, storage, use
and disposal of material
Engineering Quality of plant
integrity Availability and maintenance
Plant upgrading/modifications
Standards and codes
Management Resource allocation and
control development
Monitoring, quality control and
appraisal
Management of change
Competence/capability of
management
Responsibility and accountability
Supervision and control
Safety responsibilities
Handling emergencies
Communication Information quality
and Safety information
information Channels
Media interface/exchange
emergency response
information
Emergency communication
Procedures and Working procedures and
practices practices safety studies
Quality control
Emergency procedures
Incident reporting
Working Working conditions
Environment Welfare,
Safety culture
Immediate supervision and
support
Operator Recruitment,
Performance training personnel capabilities,
Working discipline
Safety and operating margins
Immediate and Root Causes of
Accident

Immediate Cause
• The most apparent cause
• Represent the initiators of the incidents
• It is the symptom
• Normally called unsafe acts or unsafe conditions
Root Cause of Accident
• Exists because of lack of management control
(commitment to safety policy, planning, organising,
etc.)
• Either personal related – lack of
knowledge or skills, poor
motivation, and physical
difficulties; or
• Job related – inadequate work
standards, poor maintenance or
design of equipment
What must we do to keep
accident from happening…?

• Design of process
• Management of process
• Operation of process
• Regulations

You will learn about these things in this course !