ACCIDENT CAUSATION

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AC1

Early Man

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AC2

Industrial Revolution
Factory managers reasoned that workers were hurt because Number is Up Carelessness People Error

ACCIDENT
Act of God
Cost of doing Business PEOPLE PROBLEM
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AC3

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

Industrial Accident Prevention

Social Environment and Ancestry

Fault of the Person (Carelessness)

Unsafe Act or Condition

Accident

Injury

MISTAKES OF PEOPLE
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AC4

Heinrichs 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.
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AC5

Heinrichs Theory
Corrective Action Sequence (The three Es)

Engineering
Education Enforcement
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AC6

Modern Causation Model

RESULT: -No damage or injury OPERATING ERROR MISHAP (POSSIBLE)

-Many fatalities -Major damage

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AC7

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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AC8

Examples
Operating Errors:

Being in an unsafe position Stacking supplies in unstable stacks

Poor housekeeping
Removing a guard
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AC9

Systems Defect

Revolutionized accident prevention A weakness in the design or operation of a system or program

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AC10

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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AC11

Modern Causation Model

SYSTEM DEFECTS OPERATING ERRORS MISHAP (POSSIBLE)

RESULT: -No damage or injury

Operating Errors occur because people make mistakes, but more importantly, they occur because of

-Many fatalities -Major damage

SYSTEM DEFECTS
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AC12

Modern Causation Model

Managers design the Systems
COMMAND ERROR

RESULT: -No damage or injury

SYSTEM DEFECTS

OPERATING ERRORS

MISHAP (POSSIBLE)
-Many fatalities -Major damage

System defects occur because of

MANAGEMENT / COMMAND ERROR

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AC13

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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AC14

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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AC15

Modern Causation Model

SAFETY MANAGEMENT ERROR
SAFETY PROGRAM DEFECT COMMAND ERROR

SYSTEM DEFECT

OPERATING ERROR

MISHAP

RESULTS
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AC16

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 29 300

SERIOUS MINOR CLOSE CALL

1
59 600

SERIOUS MINOR CLOSE CALL

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AC17

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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AC18

Seven Avenues
Potential countermeasures for each modern causation approach include:

1
SAFETY MANAGEMENT ERROR
TRAINING EDUCATION MOTIVATION TASK DESIGN
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2 3 4 5 6 7

AC19

Seven Avenues
Potential countermeasures for each modern causation approach include:

SAFETY PROGRAM DEFECT

REVISE INFORMATION COLLECTION ANALYSIS IMPLEMENTATION

3 4 5 6 7

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AC20

Seven Avenues
Potential countermeasures for each modern causation approach include:

1 2

COMMAND ERROR
TRAINING EDUCATION MOTIVATION TASK DESIGN

4 5 6 7

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AC21

Seven Avenues
Potential countermeasures for each modern causation approach include:

4
1 2 3
SYSTEM DEFECT

5 6 7

DESIGN REVISION VIA-- SOP - REGULATIONS - POLICY LETTERS - STATEMENTS

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AC22

Seven Avenues
Potential countermeasures for each modern causation approach include:

1 2 3 4

OPERATING ERROR
ENGINEERING TRAINING MOTIVATION

6 7

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AC23

Seven Avenues
Potential countermeasures for each modern causation approach include:

1 2 3 4 5

MISHAP

PROTECTIVE EQUIPMENT BARRIERS SEPARATION

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AC24

Seven Avenues
Potential countermeasures for each modern causation approach include:

1 2 3 4 5 6

RESULT
CONTAINMENT FIREFIGHTING RESCUE EVACUATION FIRST AID

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AC25

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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AC26

Army Systems Model

TASK
Communication Control Arrangement

Demands on soldiers
Time aspects

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AC27

Army Systems Model

PERSON
Selection Motivation

Mentally
Physically Emotionally

Positive
Negative Retention

Qualified

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AC28

Army Systems Model

TRAINING
Types
Initial
Update Remedial

Targets
Operator Supervisor Management

Considerations
Quality/Quantity

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AC29

Army Systems Model

ENVIRONMENT
Noise Weather Facilities

Lighting
Ventilation

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AC30

Army Systems Model

MATERIEL
Supplies
Equipment Machine Design Maintenance

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AC31

Army Systems Model

SAFETY MANAGEMENT ERROR SAFETY PROGRAM DEFECT Army Systems Model
Task Training Environment Materiel Person

RESULT

MISHAP

COMMAND ERROR

SYSTEM DEFECT

OPERATING ERROR

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AC33

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AC34