What is an Accident?

THEORY OF ACCIDENT
• Unplanned event results in defect(personal
CAUSATION & injury or property damage).

INVESTIGATION • Accidents are the result of the failure of

people, equipment, materials, or
environment to react as expected.
• All accidents have consequences or
outcomes.
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The Swiss Cheese Model

Purpose of Accident Investigation

• Determine the sequences of events
leading to failure.
• Identify the causes of the accident.
• Find methods to prevent accident from
recurring.

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The Swiss Cheese model of

The Swiss Cheese Model
accident causation
• The Swiss Cheese Model is such a useful tool
because it can be used not only in an accident
investigation but also to help identify potential
errors before they occur.

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The Swiss Cheese Model The Swiss Cheese Model
• Created in 1990 by James Reason, a professor of • Although this approach has always been
psychology in Manchester, England, the model convenient, it is basically a blaming mechanism
has been modified to meet the needs of and fails to expose the bigger root causes.
different occupations; but because we are
dealing with human factors, the underlying
premise is consistent.

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The Swiss Cheese Model The Swiss Cheese Model

• Within the Swiss Cheese Model, Dr. Reason • Violations are just that—a person knowingly
identifies those active failures as the final unsafe operates outside of acceptable policies and
act. Unsafe acts fall into two categories: errors and procedures. Some violations may be routine,
violations. such as a deviation within the framework of a
• Errors are skill-, decisional-, and perception-based, standard operating procedure. Others may be
such as forgetting or not knowing how to perform exceptional violations, such as freelancing.
a skill, choosing the wrong tactic, and having low
situational awareness.

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The Swiss Cheese Model The Swiss Cheese Model

• Dr. Reason identifies three areas of latent • The first latent failure, Preconditions for Unsafe
failure. As the name suggests, latent failures, Acts, involves how an individual’s or crew’s
unlike their active counterparts, may lie non condition affects performance. This includes
effective or undetected for hours, days, weeks, mental fatigue and poor communication and
or even longer, until one day they adversely coordination practices.
affect the unsuspecting person or crew.

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The Swiss Cheese Model The Swiss Cheese Model
Unsafe supervision falls into four categories:
• As with other high-risk occupations, leadership • Inadequate supervision. A lack of guidance, leadership,
is crucial. Within the Swiss Cheese Model, an and motivation.
entire slice is devoted to leadership, labeled • Planned inappropriate operations. The task, tactic, or
Unsafe Supervision. The company officer tempo of the operation puts individuals at unacceptable
risk.
position is the most crucial because this is
• Failure to correct known problems. Failure to correct
where the majority of the pivotal decisions are
problems with individuals, equipment, training, or other
made. related safety areas that are “known” to the supervisor but
are allowed to continue unobstructed.
• Supervisory violations. Rules and regulations are willfully
13 disregarded by supervisors. 14

Theories of Accident Causation

The Swiss Cheese Model
• Dr. Reason rounds out the model by including • Domino Theory
the organization itself, Organizational • Human Factors Theory
Influences, which can impact performance at all • Accident / Incident Theory
levels. When budgets are tight or funding is cut,
seemingly nonessential programs are omitted • Epidemiological Theory
or severely scaled back. Although the training • Systems Theory
division as a whole may not be cut, more costly • Combination Theory
exercises or funds for traveling to a class or
seminar can be the first to go.
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Domino Theory
Thus,
First scientific approach of accident prevention by
• Accident causation is very complex and must be W.F. Heinrich in 1931
understood adequately in order to improve
accident prevention.
Studied 75,000 industrial accidents
• 88% of all accidents are caused by unsafe acts
of people
• 10% by unsafe conditions
• 2% by unavoidable causes (acts of God)

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 Domino Theory.

• The occurrence of an injury invariably results

from a completed sequence of factors, the last
one of these being the injury itself. The accident
which caused the injury is in turn invariably
caused or permitted directly by the unsafe act of
a person and/or a mechanical or physical hazard.

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Heinrich’s Theorems
Domino Theory
INJURY - caused by accidents.
“Industrial Accident Prevention”
•

• 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
Social Fault of the Unsafe Act was raised and educated.
Environment Person or Accident Injury
and Ancestry (Carelessness Condition
)

MISTAKES OF PEOPLE 21 22

Domino Theory Domino Theory

Heinrich established the ‘Domino theory’ which is • 2. Fault of person (carelessness); Faults of
based on five sequential factors as following : person or carelessness are negative features of a
1. Ancestry and social environment; Ancestry and person personality although these unwanted
social environment are the process of acquiring characteristics might be acquired. The result of
knowledge of customs and skills in the workplace. carelessness is unsafe act/conditions.
Lack of skills and knowledge of performing tasks,
inappropriate social and environmental conditions
will lead to fault of person.

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Domino Theory Heinrich’s Axioms of Industrial
Safety
3. Unsafe act and/or mechanical or physical • Accidents are preventable.
condition; Unsafe acts/conditions include the • Accident prevention techniques are analogous
errors and technical failures which cause the with best quality and production techniques.
accident. • Management should be responsible for safety.
4. Accident; Accidents are caused by unsafe • Supervisor is the key person.
acts/conditions and subsequently lead to injuries
• Accidents have both direct costs and hidden
5. Injury; Injuries are the consequences of the costs.
accidents.

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Heinrich’s Axioms of Industrial Human Factors Theory

Safety
• Heinrich’s Domino Theory – Corrective Action • Human factors model is based on the idea that
Sequence (The three “E”s) the human errors are the major cause of
• Engineering – Control hazards through product accidents; however human unsafe behavior as
design or process change well as poor design of workplace and
• Education – Train workers regarding all facets of environment which do not consider the human
safety – Impose on management that attention limitation, are considered as contributory
to safety pays off factors.
• Enforcement – Insure that internal and external
rules, regulations, and standard operating
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procedures are followed by workers as well as
management.

Human Factors Theory

Human Factors Theory
• The human factors theory of accident causation
attributes accidents to a chain of events Overload Inappropriate Inappropriate
ultimately caused by human error. It consists of •Environmental
Response Activities
•Detecting a
three broad factors that lead to human error: Factors (noise,
hazard but not
•Performing tasks
distractions without the
overload, inappropriate response, and correcting it
adequate training
•Internal Factors
inappropriate activities. (personal problems, •Removing
•Misjudging the
emotional stress) safeguards from
degree of risk
machines and
•Situational Factors involved with a
equipment
(unclear given task
instructions, risk •Ignoring safety
level)
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Human Factors Theory Petersen’s Accident/Incident
Theory
• Behavior model blame humans for occurrence Extension of human factors theory. Here the
of accidents. Errors in this approach are likely to following new elements are introduced:
be done by humans in different environmental Ergonomic traps – These are incompatible work
conditions. Humans are blamed just for their stations, tools or expectations (management
unsafe behavior. failure)
Decision to err – Unconscious or conscious
(personal failure)
Systems failure – Management failure (policy,
training, etc.)
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Petersen’s Accident/Incident Petersen’s Accident/Incident

Theory Theory
• In this model, overload, ergonomic traps, or a Overload Ergonomic Traps Decision to Err
decision to error may lead to human error. The •Pressure •Misjudgment of
•Incompatible
decision to error may be conscious and based on •Fatigue workstation (i.e. the risk
size, force, reach,
logic, or it may be unconscious. •Motivation
feel)
•Unconscious
desire to err
•Drugs
• A variety of pressures such as tight deadlines, •Incompatible •Logical decision
•Alcohol
peer pressure, and budget factors can lead to expectations based on the
•Worry situation
unsafe behaviors'. Another factor that can
influence such a decision is the "It won't happen Human Error
to me" syndrome Systems Failure
Policy Inspection Accident
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Responsibility Correction
Training Standards Injury/Damage

Petersen’s Accident/Incident Petersen’s Accident/Incident

Theory Theory
The systems failure component is an important • System failure is normally caused by several acts
contribution of Petersen's theory. 1st, it shows the or approaches which do not fulfils the
potential for a causal relationship between requirements of occupational safety and health
management decisions or management behavior, such as the following.
and safety.
2nd, it establishes management's role in
accident prevention as well as the broader
concepts of safety and health in the workplace.

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Petersen’s Accident/Incident
Epidemiological Theory
Theory
• 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; and
• Employees are not given sufficient safety training. 37 38

Epidemiological Theory
Epidemiological Theory
Predisposition Situational
• Traditional approaches focused on
Characteristics Characteristics • accidents and resulting injuries.
•Risk assessment by
•Susceptibility of people individuals
•Perceptions •Peer pressure • Current trend includes a broader perspective of
•Environmental factors •Priorities of the • industrial hygiene issues.
supervisor
•Attitude
• Industrial Hygiene concerns environmental
issues that can lead to sickness, disease,
Can cause or prevent 39 impaired health. 40
accident conditions

Epidemiological Theory
Epidemiological Theory
• Used to study causal relationships between • Industrial hygiene concerns environmental
environmental factors and disease. factors that, if not addressed properly,
• Theory supposes these models must also can lead to sickness, disease, or other forms of
appropriate for studying the casual relationships health impairment. This trend has, in turn, led to
between environmental factors and accidents. the development of an epidemiological theory
of accident causation.
• Note: Causal NOT Correlational Relationships !!!

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Epidemiological Theory Firenzie’s Systems Theory
Person/Machine/Environment
• For example, If an employee who is particularly
susceptible to peer pressure(predisposition Information Gathering
characteristic) is pressured by his
coworkers(situational characteristic) to speed Risks Assessment Stressors
up his operation, a decision that might Decision Making
lead to carelessness and the result will Task Performance
be an increased
Stressors can cloud the judgment during information
probability of a workplace accident.
gathering, risk weighing, decision making processes.
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Firenzie’s Systems Theory

• Firenzie’s theory is based on interaction among Systems Theory Model
three components: person, machine, and
environment.
• Human variables of information, decisions, and
perception of risks combine with machine
Machine Person Task to be
hazards and environmental factors affecting the Collect Weigh Make
performed
information risks decision
likelihood of an accident. Environment

Interaction

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Systems Theory Model Systems Theory Model

System - interacting components intended to meet a
• For example, as a person operates a noisy bulldozer
common goal. A change in any component affects
the entire system on a hot day, other activities must take place for the
operator to safely and effectively perform the job.
• Systems theory
The person consciously or unconsciously will collect
• Components Person Machine Environment
information, weigh risks, and make decisions as to
Collect information, weigh risks, make decisions how to perform the task.
• Systems theory
• How close should the bulldozer get to the 20-
• Stressors cloud judgment Job requirements, foothigh spoil bank or the electrical power lines?
Worker’s abilities & limitations, Benefit if task
accomplished, Loss if task is tried but fails, Loss if • How fast should it be moving? **
task is not attempted The operator, based on knowledge and experience,
makes countless decisions—all of which affect the
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probability of an accident.
Combination theory Combination theory
• Factors combined in random fashion to cause accidents. There are more than single cause which contribute
ACCIDENT CAUSATION or lead to both unsafe act and unsafe condition
and finally occurrence of an accident.
• Unlike simplified theory of domino, there are
causes and sub-causes when an accident
happens.
• Through identification of these multiple
contributing causes of accident, the unsafe acts
and unsafe conditions should be prevented
49 from arising. 50

Combination theory Combination theory

• Combination theory is an outgrowth of the According to this theory, the contributory factors
Domino Theory, but it suggests that for a single can be grouped into the following two categories:
accident there may be many contributory • Behavioral. This category includes factors
factors, causes and sub-causes, and that certain pertaining to the worker, such as improper
combinations of these give rise to accidents. attitude, lack of knowledge, lack of skills, and
inadequate physical and mental condition.
• Environmental. This category includes improper
guarding of other hazardous work elements and
degradation of equipment through use and
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51 unsafe procedures. 52

Combination theory Also,

• Drugs and alcohol are the root or a contributing
cause of many workplace accidents every year.
Approximately 77 percent of drug users are
employed, and more than a third of all workers
between 18 and 25 are drinkers.
• Clinical depression is an invisible problem in the
workplace. However, it can be a major cause of
accidents. One in 20 people suffer from clinical
depression, which is the root cause of more than
53 200 million lost workdays annually. 54
 Accident investigation
• Management failures are another leading cause • Accident investigation is the process of
of accidents on the job. If management is determining the root causes of accidents, on-
serious about workplace safety and health, it the-job injuries, property damage, and close calls
must establish expectations, provide training, in order to prevent them from occurring again.
evaluate employee performance with safety in • Accident investigation will lead you to the real
mind, and reinforce safe and healthy behavior. cause of why something happened, and armed
• There is a strong correlation between obesity with that knowledge, you can take affirmative
and injuries, suggesting a need to promote steps in order to prevent them from occurring
optimal body weight as an injury prevention again.
strategy. 55 56

HOW DO YOU DO IT? HOW DO YOU DO IT?

• determine company or individual liability in case of
Workplace accidents should be investigated as future legal action
soon as possible after they occur. The goals of a • determine the need for repairs or replacement of
timely and thorough accident investigation should damaged items
be to: • determine the need for additional education and
• determine the cause of the accident training for employees. A thorough and complete
• prevent the accident from happening again accident investigation involves several steps,
specifically:
• improve health and safety conditions in the
workplace • background investigation
• site investigation
• determine whether a violation of federal or state
safety and health standards contributed to the • interviews
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accident • analysis and reporting.

Be Prepared(Management) Conducting the Investigation

• Develop a policy for accident investigation • Determine sequence of events leading to
Routinely audit policy to: accident.
- ensure personnel understand their role • Interview witnesses.
- system is driving corrective actions • Document the scene of accident before any
changes are made.
Assign responsibilities to personnel: • Review all information (procedures,
- employee must be trained to investigate equipment manuals).
- investigator should know process 59 60