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ACCIDENT

CAUSATION

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Early Man

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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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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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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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Heinrichs Theory
Corrective Action Sequence
(The three Es)

Engineering

Education

Enforcement
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Modern
Causation
Model
RESULT:
OPERATINGE
RROR

MISHAP
(POSSIBLE)

No damage
or injury

- Many fatalities
- Major damage

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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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Examples
Operating Errors:

Being in an unsafe position

Stacking supplies in unstable


stacks

Poor housekeeping

Removing a guard
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Systems Defect

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

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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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11

Modern
Causation
Model
SYSTEM
DEFECTS

OPERATING
ERRORS

RESULT:

MISHAP
(POSSIBLE)

- No damage
or injury
- Many fatalities
- Major damage

Operating Errors occur because


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

SYSTEM DEFECTS
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Modern Causation Model


Managers design the Systems
COMMAND
ERROR

SYSTEM
DEFECTS

RESULT:

OPERATING
ERRORS

MISHAP
(POSSIBLE)

- No damage
or injury
- Many fatalities
- Major damage

System defects occur because of

MANAGEMENT / COMMAND ERROR


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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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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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Modern Causation Model


SAFETY
MANAGEMENT
ERROR

SAFETY
PROGRAM
DEFECT

COMMAND
ERROR

SYSTEM
DEFECT

OPERATING
ERROR

MISHAP

RESULTS
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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

1
29
300

SERIOUS
MINOR
CLOSE CALL

RECENT STUDIES

1
59
600

SERIOUS
MINOR
CLOSE CALL

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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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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
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Seven Avenues
Potential countermeasures for each modern
causation approach include:

2
1

SAFETY
PROGRAM
DEFECT

3 4 5 6 7

REVISE INFORMATION
COLLECTION
ANALYSIS
IMPLEMENTATION
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Seven Avenues
Potential countermeasures for each modern
causation approach include:

3
1 2

4 5 6 7

COMMAND
ERROR
TRAINING
EDUCATION
MOTIVATION
TASK DESIGN

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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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Seven Avenues
Potential countermeasures for each modern
causation approach include:

5
1 2 3 4

OPERATING
ERROR

6 7

ENGINEERING
TRAINING
MOTIVATION

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Seven Avenues
Potential countermeasures for each modern
causation approach include:

6
1 2 3 4 5

MISHAP

PROTECTIVE EQUIPMENT
BARRIERS
SEPARATION

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Seven Avenues
Potential countermeasures for each modern
causation approach include:

7
1 2 3 4 5 6

RESULT
CONTAINMENT
FIREFIGHTING
RESCUE
EVACUATION
FIRST AID

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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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Army Systems Model


TASK
Communication Control
Arrangement
Demands on soldiers
Time aspects

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Army Systems Model


PERSON
Selection
Mentally
Physically

Motivation
Positive
Negative

Emotionally

Retention

Qualified

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Army Systems Model


TRAINING
Types

Targets

Considerations

Initial

Operator

Quality/Quantity

Update

Supervisor

Remedial

Management

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Army Systems Model


ENVIRONMENT
Noise
Weather
Facilities
Lighting
Ventilation
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Army Systems Model


MATERIEL
Supplies
Equipment
Machine Design
Maintenance

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Army Systems Model


SAFETY
MANAGEMENT
ERROR
SAFETY
PROGRAM
DEFECT

COMMAND
ERROR

Army Systems
Model

RESULT

Task
Training
Environment
Materiel
Person

MISHAP

SYSTEM
DEFECT

OPERATING
ERROR

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ARE THERE ANY QUESTIONS?

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