Accident Causation Theories and Concepts

Group 1 – Safety Eng’g

Members:
Serote, Jerico
Dumo, Art Emmanuel
Balagbagan, Mary Grace
Valdriz, Jonas

Accidents are defined as unplanned occurrences which result in injuries,

fatalities, loss of production or damage to property and assets. Preventing accidents is
extremely difficult in the absence of an understanding of the causes of accidents. Many
attempts have been made to develop a prediction theory of accident causation, but so
far none has been universally accepted. Researchers from different fields of science
and engineering have been trying to develop a theory of accident causation which will
help to identify, isolate and ultimately remove the factors that contribute to or cause
accidents.

It’s important to note that OSHA uses the term “incident” to refer to these
events, while The National Safety Council – and typically the general public on the
whole – uses the term “accident.”

“Accident” as defined by The National Safety Council: An accident is an undesired event

that results in personal injury or property damage. This definition implies two important
points. First, accidents are unavoidable; the chance of one occurring will virtually always
be present. Second, the chance of an accident occurring is a variable that can be
changed. While it is impossible to prevent all accidents, it is possible to decrease their
rate of occurrence. Understanding the cause of such phenomenon is key to decreasing
the rate at which accidents occur. Determining the true root cause of each accident is
the only way to formulate effective prevention strategies.

Accident Causation Theories are used as models to help predict and prevent
accidents.

Theories of Accident Causation

There are several major theories concerning accident causation, each of which has
some explanatory and predictive value.
1.The domino theory developed by H. W. Heinrich, a safety engineer and pioneer in
the field of industrial accident safety.
2. Human Factors Theory
3. Accident/Incident Theory
4. Epidemiological Theory
5. Systems Theory
6. The energy release theory, developed by Dr. William Haddon, Jr., of the Insurance
Institute for Highway Safety.
7. Behavior Theory
Accident theories guide safety investigations. They describe the scope of an
investigation.

The Domino Theory (Heinrich’s Domino Theory)

 According to W.H. Heinrich (1931), who developed the so-called domino theory,
88% of all accidents are caused by unsafe acts of people, 10% by unsafe actions and
2% by “acts of God”. He proposed a “five-factor accident sequence” in which each
factor would actuate the next step in the manner of toppling dominoes lined up in a row.
The sequence of accident factors is as follows:

1. ancestry and social environment

2. worker fault
3. unsafe act together with mechanical and physical hazard
4. accident
5. damage or injury.

In the same way that the removal of a single domino in the row would interrupt the
sequence of toppling, Heinrich suggested that removal of one of the factors would
prevent the accident and resultant injury; with the key domino to be removed from the
sequence being number 3. Although Heinrich provided no data for his theory, it
nonetheless represents a useful point to start discussion and a foundation for future
research.

The accident triangle, also known as Heinrich's triangle or Bird's triangle, is a

theory of industrial accident prevention. It shows a relationship between serious
accidents, minor accidents and near misses and proposes that if the number of minor
accidents is reduced then there will be a corresponding fall in the number of serious
accidents.
The triangle shows a relationship between the number of accidents resulting in
serious injury, minor injuries or no injuries. The relationship was first proposed in 1931
by Herbert William Heinrich in his Industrial Accident Prevention: A Scientific Approach.
Heinrich was a pioneer in the field of workplace health and safety. He worked as an
assistant superintendent for an insurance company and wanted to reduce the number of
serious industrial accidents. He commenced a study of more than 75,000 accident
reports from the insurance company's files as well as records held by individual industry
sites. From this data he proposed a relationship of one major injury accident to 29 minor
injury accidents, to 300 no-injury accidents. He drew the conclusion that, by reducing
the number of minor accidents, industrial companies would see a correlating fall in the
number of major accidents. The relationship is often shown pictorially in the form of a
triangle or pyramid. The triangle was widely used in industrial health and safety
programmes over the following 80 years and was described as a cornerstone of health
and safety philosophy. Heinrich's theory also suggested that 88% of all accidents were
caused by a human decision to carry out an unsafe act.
 From the figure, Heinrich identified five stages of accident causation. The first stage,
the social environment and ancestry, encompasses anything that may lead to
producing undesirable traits in people. It is worth noting that Heinrich’s inclusion of
genetics and ancestry is very much a product of the time it was written. A modernized
version of this theory would likely use the term “inherited behavior,” similar to how
alcoholism and temperaments can be inherited. This stage of accident causation is
quite similar to the social learning theories discussed in the criminological theories
chapter of this textbook.
The second stage, faults of a person, refers to personal characteristics that are
conducive to accidents. For example, having a bad temper may lead to spontaneous
outbursts and disregard for safety. Similarly, general recklessness can also be one of
the manifestations of poor character. Ignorance, such as not knowing safety regulations
or standard operating procedures, is also an example of this stage.
The third stage, an unsafe act or condition, is often the identifiable beginning of a
specific incident. Unlike the first two stages, which affect the probability of accidents
occurring, this stage is closer to the accident in terms of temporal proximity. This can
include a specific act that is unsafe, such as starting a machine without proper warning,
or failing to perform appropriate preventative actions, such as using guardrails or other
safety measures. In essence, this stage entails acts (or failures to act) that occasionally
cause accidents.
The next stage, logically, is the accident itself. This, in and of itself, needs little
explanation. It is, simply, when something occurs that is undesirable and not intended.
The final stage, injury, is the unfortunate outcome of some accidents. Whether an
injury occurs during an accident is often a matter of chance and not always the
outcome.
This relationship highlights the relationships between stages in terms of causality.
An accident occurring is not a sufficient cause for an injury, but it is a necessary one.
Similarly, the undesirable characteristics in stage two do not always occur in poor
environments, but could not occur without such environments. Given this necessary
causality, the most important policy implication is to remove at least one of the dominos,
which can in turn lead to a healthy subculture through positive accident prevention
training and seminars. An organization may not be able to weed out all of the people
with undesirable characteristics, but it can have a procedure in place for dealing with
accidents to minimize injury and loss.
Heinrich's Axioms of Industrial Safety
1. Injuries result from a series of preceding factors.
2. Accidents occur as the result of physical hazard or an unsafe act.
3. Most accidents are the result of unsafe behavior.
4. Unsafe acts and hazards do not always result in immediate accidents and injuries.
5. Understanding why people commit unsafe acts helps to establish guidelines for
corrective actions.
6. The severity of the injury is largely fortuitous and the accident that caused it is
preventable.
7. Best accident prevention techniques are analogous to best quality / productivity
techniques.
8. Management should assume safety responsibilities.
9. The supervisor is the key person in the prevention of industrial accidents.
10. Cost of accidents include both direct costs and indirect costs.

Heinrich's Domino Theory – Critical Issues

• The factor preceding the accident (the unsafe act or the mechanical or physical
hazard) and it should receive the most attention.
• Heinrich felt that the person responsible at a company for loss control should be
interested in all five factors, but be concerned primarily with accidents and the
proximate causes of those accidents.
• Heinrich also emphasized that accidents, not injuries or property damage, should be
the point of attack.
– An accident is any unplanned, uncontrolled event that could result in personal injury or
property damage. For example, if a person slips and falls, an injury may or may not
result, but an accident has taken place.

Heinrich's Domino Theory – Corrective Action Sequence

(The three ''E''s)
Engineering
– Control hazards through product design or process change
• Education
– Train workers regarding all facets of safety
– Impose on management that attention to safety pays off
• Enforcement
– Insure that internal and external rules, regulations, and standard operating procedures
are followed by workers as well as management.

Human Factors Theory (Ferrell’s Human Factor Model)

Heinrich posed his model in terms of a single domino leading to an accident. The
premise here is that human errors cause accidents. These errors are categorized
broadly as:
• Overload
- The work task is beyond the capability of the worker
1. Includes physical and psychological factors
2. Influenced by environmental factors, internal factors, and situational factors
• Inappropriate Worker Response
- To hazards and safety measures (worker’s fault)
- To incompatible work station (management, environment faults)
• Inappropriate Activities
- Lack of training and misjudgment of risk
But the structure of this theory is still a cause/effect format

Unlike Heinrich, who explained accidents with a single chain reaction in vague
terms, Ferrell’s model incorporates multiple causes and is very specific about these
causes (Heinrich, Petersen, & Roos, 1980). Additionally, Ferrell defines accidents in
terms of being the result of an error by an individual. As such, he explains his theory
using the assumption that accidents are caused by one person.
Ferrell identifies three general causes of accidents: overload, incompatibility and
improper activities. Each of these are actually broad categories that contain several
more specific causes. Improper activities is perhaps the simplest of the concepts, as it
encompasses two straight forward sources of accidents. First, it is possible that the
responsible person simply didn’t know any better. Alternatively, he or she may have
known that an accident may result from an action, but deliberately chose to take that
risk. The incompatibility cause is slightly more complex than improper activities. It
encompasses both an incorrect response to a situation by an individual, as well as
subtle environmental characteristics, such as a work station that is incorrectly sized.
The remaining cause, overload, is the most complex of Ferrell’s causes. It can
further be broken down into three subcategories. First, the emotional state of the
individual accounts for part of an overload. These states include conditions such as
unmotivated and agitated. Second, the capacity refers to the individual’s physical and
educational background. Physical fitness, training, and even genetics play a part of this.
Situational factors, such as exposure to drugs and pollutants, as well as job related
stressors and pressures, also affect one’s capacity. Finally, the load of the individual
can also contribute to an overload. This includes the difficulty of the task, the negative
or positive effects of the environment (noise, distractions, etc.), and even the danger
level of the task. Separate from each other, overload, incompatibility, and improper
activities can all cause a human error to occur, which can lead to an accident.

Accident/Incident Theory (Petersen’s Accident/Incident Model)

Extension of human factors theory. Here the following new elements are introduced:
• Ergonomic traps
– These are incompatible work stations, tools or expectations (management failure)
• Decision to err
– Unconscious or conscious (personal failure)
• Systems failure
– Management failure (policy, training, etc.)

Petersen’s model is largely an expansion upon Ferrell’s Human Factor Model

(Heinrich, Petersen, & Roos, 1980). The notion of an overload, caused by capacity,
state, or load, is very similar to Ferrell’s work. However, a few changes and refinements
do exist. First, Petersen conceptualized the environmental aspect of incompatibility
(work station design and displays/controls) as a different part of the model, calling them
ergonomic traps. Additionally, Petersen also separated a decision to err from the
overload cause. Further, Petersen also specified separate reasons to choose to err.
These reasons include: a logical decision due to the situation (primarily for financial cost
and temporal deadlines), an unconscious desire to err (psychological failings), and
perceived low probability of an accident occurring. The latter of those reasons, the
perception of low accident probability, can include both actual instances of an accident
being extremely unlikely, as well as the natural inclination of a human to disregard his or
her own mortality. This aspect of Petersen’s model is akin to criminology’s rational
choice perspective (see the criminological theories chapter), as it makes the same
assumptions of human rationality and hedonistic calculus.
 Another noteworthy contribution is Petersen’s recognition that human error is
only part of a larger model. A system failure, the inability of the organization to correct
errors, was added as a possible mediator between errors and accidents. These failures
have a range of possible occurrences. The failure of management to detect mistakes
and a lack of training are but two examples of systems failures. Even poor policy itself
can lead to a systems failure that does not prevent an accident from occurring following
a human error.

Epidemiological Theory
Epidemiology
– This field studies relationship between environmental factors and disease
– Can be used to study causal factors in a relationship
Two key components:
1 Predisposition characteristics
• tendencies may predispose worker to certain actions
2 Situational characteristics
• peer pressure, poor attitude, risk taking
Together these characteristics can cause or prevent accidents that a person
predisposed to a given situation or condition may succumb to.

Summary - Traditional Chain-of-Events

Accident Causality Models
• Explain accidents in terms of multiple events, sequenced as a forward chain over time.
• Events linked together by direct relationships (ignore indirect relationships).
• Events almost always involve component failure, human error, or energy-related
events.
•Causality models form the basis for most safety-engineering and reliability engineering
analyses and/or designs.

Limitations of Event-Chain Causality Models

Neglects social and organizational factors
• Does not adequately account for human error
– One cannot simply and effectively model human behavior by decomposing it into
individual decisions and actions. One cannot study human error in isolation from:
o physical and social context;
o value system in which behaviors takes place; and
o dynamic work process
• Neglects adaptation
– Major accidents involve systematic migration of organizational behavior to higher
levels of risk.

Reliability Engineering vs. System Safety

• Both arose after World War II
• Reliability engineering is often confused with system safety engineering, but they are
different and sometimes even conflict
• Reliability engineering focuses on quantifying probabilities of failure.
• System safety analysis (e.g., fault tree analysis) focuses on eliminating and controlling
hazards
– Considers interactions among components and not just component failures
– Includes non-technical aspects of systems
• Highly reliable systems may be unsafe and safe systems may not be reliable.

A Systems Theory Model of Accidents

Accidents arise from interaction among humans, machines, and the environment.
-Not simply chains of events or linear causality, but more complex types of causal
connection.
Under normal circumstances chances of an accident is low. Rather than looking at the
environment as being full of hazards and people prone to errors, system safety
assumes harmony (steady state) exists between individuals and the work environment
Safety is an emergent property that arises when components of system interact with
each other within a larger environment.
- A set of constraints related to behavior of components in system enforces that
property.
- Accidents when interactions violate those constraints (a lack of appropriate
constraints on the interactions).
- Software as a controller embodies or enforces those constraints.

Road accidents are seen as failures of the whole traffic system (interaction
between the three elements) rather than a failure of the driver.
The driver is a victim – this assumes the demands that the traffic system puts on
the driver is too complex for the driver’s limited capacity to process information.
• As a result of this assumption the system must be designed to be less complex, which
prevents errors from occurring.
• “The energy and barriers perspective”: The system must also reduce the negative
consequences of errors, i.e., introduce safety margins that allows the driver to incur an
error without being hurt too seriously.

Haddon's Energy Release Theory

Willam Haddon a medical doctor and the adminstrator of NHTSA at one point in time, in
1966 helped to impose the following regulations for new cars:
1. Seat belts for all occupants
2. Energy-absorbing steering column
3. Penetration-resistant windshield
4. Dual braking systems
5. Padded instrument panel
6. All measures correspond with the energy and barrier concept
• The systems theory approach, in contrast to the energy release theory, treats the
driver as a passive responder in his environment.
• The evidence is that he is in fact an active participant, regulating his/her level of
preferred risk
• Risk compensation/ behavioural adaptation: operators within a system may take
advantage of safety measures in other ways than to increase safety
• Two basic forms of compensation to road safety measures:
– Increased speed
– Reduced attention

Those who accept the energy transfer theory put forward the claim that a worker
incurs injury or equipment suffers damage through a change of energy, and that for
every change of energy there is a source, a path and a receiver. This theory is useful for
determining injury causation and evaluating energy hazards and control methodology.
Strategies can be developed which are either preventive, limiting or ameliorating with
respect to the energy transfer.

Control of energy transfer at the source can be achieved by the following means:
o elimination of the source
o changes made to the design or specification of elements of the work station
o preventive maintenance.

The path of energy transfer can be modified by:

o enclosure of the path
o installation of barriers
o installation of absorbers
o positioning of isolators.

The receiver of energy transfer can be assisted by adopting the following measures:
o limitation of exposure
o use of personal protective equipment.

Behavioral Theory
• Often referred to as behavior-based safety (BBS)
• 7 basic principles of BBS
– Intervention
– Identification of internal factors
– Motivation to behave in the desired manner
– Focus on the positive consequences of appropriate behavior
– Application of the scientific method
– Integration of information
– Planned interventions
Behavior-based safety (BBS) is the "application of science of behavior change to
real world safety problems". or "A process that creates a safety partnership between
management and employees that continually focuses people's attentions and actions on
theirs, and others, daily safety behavior." BBS "focuses on what people do, analyzes
why they do it, and then applies a research-supported intervention strategy to improve
what people do". At its very core BBS is based on a larger scientific field called
organizational behavior management.
In a safety management system based upon the hierarchy of hazard control,
BBS may be applied to internalise hazard avoidance strategies or administrative
controls (including use of personal protective equipment), but should not be used in
preference to the implementation of reasonably practicable safety measures further up
the hierarchy.
To be successful a BBS program must include all employees, from the CEO to
the front line workers including hourly, salary, union employees, contractors and sub-
contractors. To achieve changes in behavior, a change in policy, procedures and/or
systems most assuredly will also need some change. Those changes cannot be done
without buy-in and support from all involved in making those decisions.
 BBS is not based on assumptions, personal feeling, and/or common knowledge.
To be successful, the BBS program used must be based on scientific knowledge.

Combination Theory
• Accidents may/may not fall under any one model
• Result from factors in several models.
• One model cannot be applied to all accidents
References:
https://academic.csuohio.edu/duffy_s/Section_03.pdf
http://www.iloencyclopaedia.org/part-viii-12633/accident-prevention/92-56-accident-
prevention/theory-of-accident-causes
https://en.m.wikipedia.org/wiki/Accident_triangle
https://www.slideshare.net/shibrah76/theory-41868344#targetText=Heinrich's
%20Axioms%20of%20Industrial%20Safety,to%20best%20quality%20%2F
%20productivity%20techniques.&targetText=The%20supervisor%20is%20the%20key
%20person%20in%20the%20prevention%20of%20industrial%20accidents.
http://wps.prenhall.com/chet_goetsch_occupation_7/139/35769/9157107.cw/-/9157132/i
ndex.html#targetText=The%20human%20factors%20theory%20of,inappropriate
%20response%2C%20and%20inappropriate%20activities.