Accident Causation Theory

ACCIDENT
CAUSATION
1
Early Man
2
Industrial Revolution
Factory managers reasoned that
workers were hurt because —
Number is Up
Carelessness People Error
ACCIDENT
Cost of doing
Act of God
Business
PEOPLE PROBLEM 3
Domino Theory
1932 First Scientific Approach to
Accident/Prevention - H.W. Heinrich.
“Industrial Accident Prevention”
Social Fault of the Unsafe Act

Environment Person or Accident Injury
and Ancestry (Carelessness) Condition
MISTAKES OF PEOPLE 4
HEINRICH’S THEOREMS
 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.
5
Heinrich’s Theory
Corrective Action Sequence

(The three “E”s)
 Engineering
 Education
 Enforcement
6
Modern
Causation Model
RESULT:
-No damage
OPERATING MISHAP or injury
ERROR (POSSIBLE)
-Many fatalities
-Major damage
7
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. 8
Examples
Operating Errors:
Being in an unsafe position

Stacking supplies in unstable stacks
Poor housekeeping
Removing a guard
9
Systems Defect
 Revolutionized accident
prevention
 A weakness in the
design or operation of
a system or program
10
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
11
Modern
Causation Model RESULT:
-No damage
or injury
SYSTEM OPERATING MISHAP
DEFECTS ERRORS (POSSIBLE)
-Many
fatalities
Operating Errors occur because -Major damage
people make mistakes,
but more importantly,
they occur because of
SYSTEM DEFECTS
12
Modern Causation Model
Managers design the Systems
COMMAND
ERROR RESULT:
-No damage
or injury
SYSTEM OPERATING MISHAP
DEFECTS ERRORS (POSSIBLE)
-Many
fatalities
-Major damage
System defects occur because of
MANAGEMENT / COMMAND ERROR 13
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 14
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
15
Modern Causation Model
SAFETY SAFETY
COMMAND
MANAGEMENT PROGRAM
ERROR
ERROR DEFECT
SYSTEM OPERATING
MISHAP
DEFECT ERROR
RESULTS
16
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.
INITIAL STUDIES RECENT STUDIES
1 SERIOUS 1 SERIOUS
29 MINOR 59 MINOR
300 CLOSE CALL 600 CLOSE CALL

17
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 18
SEVEN AVENUES
Potential countermeasures for each modern
causation approach include:
1
SAFETY
MANAGEMENT
ERROR
2 3 4 5 6 7
TRAINING
EDUCATION
MOTIVATION
TASK DESIGN
19
SEVEN AVENUES
2
SAFETY
1 PROGRAM
DEFECT
3 4 5 6 7
REVISE INFORMATION
COLLECTION
ANALYSIS
IMPLEMENTATION
20
SEVEN AVENUES
3
COMMAND
1 2 ERROR 4 5 6 7
TRAINING
EDUCATION
MOTIVATION
TASK DESIGN
21
SEVEN AVENUES
4
SYSTEM
1 2 3 DEFECT 5 6 7
DESIGN REVISION VIA--
- SOP
- REGULATIONS
- POLICY LETTERS
- STATEMENTS
22
SEVEN AVENUES
5
OPERATING
1 2 3 4 ERROR 6 7
ENGINEERING
TRAINING
MOTIVATION
23
SEVEN AVENUES
6
1 2 3 4 5 MISHAP 7
PROTECTIVE EQUIPMENT
BARRIERS
SEPARATION
24
SEVEN AVENUES
7
1 2 3 4 5 6 RESULT
CONTAINMENT
FIREFIGHTING
RESCUE
EVACUATION
FIRST AID 25
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 Systems Model are:

Task
Person
Training
Environment
Materiel
26
Systems Model
TASK
• Communication Control
• Arrangement
• Demands on workers
• Time aspects
27
Systems Model
PERSON
Selection Motivation
• Mentally • Positive
• Physically • Negative
• Emotionally • Retention
• Qualified
28
Systems Model
TRAINING
Types Targets Considerations
• Initial • Operator • Quality/Quantity
• Update • Supervisor
• Remedial • Management
29
Systems Model
ENVIRONMENT
• Noise
• Weather
• Facilities
• Lighting
• Ventilation
30
Systems Model
MATERIEL
• Supplies
• Equipment
• Machine Design
• Maintenance
31
Systems Model
SAFETY Systems
MANAGEMENT Model RESULT
ERROR • Task
• Training
• Environment
SAFETY • Materiel
PROGRAM • Person MISHAP
DEFECT
COMMAND SYSTEM OPERATING

ERROR DEFECT ERROR
33
Thank You
34

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ACCIDENT

Social Fault of the Unsafe Act

Corrective Action Sequence

How accidents are caused &

Being in an unsafe position

Initial studies show for each disabling injury, there

INITIAL STUDIES RECENT STUDIES

300 CLOSE CALL 600 CLOSE CALL

There are seven avenues through which we

A system is simply a group of interrelated parts which,

The elements of the Systems Model are:

COMMAND SYSTEM OPERATING

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