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Overview/Description This course helps to know the way of happening of accident/ incident and find out the different causes involved through various available theories. Also gives an idea to interpret these causes while doing accident / incident investigation to reach preventive actions with respect to them. Target Audience

This training course is intended only for Foreman, Engineer or Managers. Expected 3. 0 hour Lesson Objectives Duration

1. To know various theories on accident / incident. 2. To know interrelation of causes in accident / incident occurrences. 3. To develop knowledge to interpret those causes in accident / incident Investigation. 4. To develop knowledge about potential causes for use in accident / incident prevention.
Course Overview I. Theories on Accident / Incident a. Domino Theories Heinrich’s Domino Theory Bird’s Domino Updated Theory

b. c. d. e. f. g. h.

Human Factors Theory Peterson Accident / Incident Theory Epidemiological Theory System Theory Model Swiss Cheese Theory Model Energy Release Theory Combination Model

II. Interpretation of Causes in Accident / Incident Investigation & Prevention

I. Theories on Accident / Incident a. Domino Theory (and modifications) Heinrich’s Domino Theory As one could easily guess from the commonly used name for Heinrich’s theory, Heinrich (1936) explained accidents using an analogy to dominos falling over one another and creating a chain of events.

Figure #1: Heinrich Accident Analysis While this theory is not the most advanced or complex theory, it is especially noteworthy as one of the first scientific theories used to explain accidents. It is often still referenced today, seven decades later. When dominos fall over, each tips the next enough to push it over and continue the process until all the connected dominos have fallen. However, if just a single domino is removed, the entire process ceases. Heinrich explains accident causation in the same way:

Figure #2: Heinrich’s Domino Theory

As you can see 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. More precisely, this includes the nature and nurture aspects of someone’s background. Genetics, poor parenting/socializing, and an unhealthy subculture are all examples of characteristics of nature and nurture that can negatively influence individuals and lead to the next stage of accident causation. 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, especially the parenting and subculture aspects, is quite similar to the social learning theories. 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 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 one of the dominos (though try for more than one just to be safe); produce a healthy subculture through

positive accident prevention training and seminars, attempt to weed out people with undesirable characteristics (or otherwise address said traits), and, if all else fails, have a procedure in place for dealing with accidents to minimize injury and loss. What is Heinrich Dominos Theory? Explain.

Frank Bird's Theory (Domino Updated) Heinrich’s theory of domino sequence is updated by Frank Bird Jr. to explain the circumstances that lead to losses (injury) in the chronological order of five dominoes. 1. 2. 3. 4. 5. Lack of control - Management. Basic causes - Origins. Immediate causes - Symptoms. Accident - Contact, and Figure #3: Bird’s Updated Domino Theory Injury/damage - Loss.

Lack of control is the first domino and refers the fourth function of the management (planning, organizing, directing, controlling and coordinating). It involves accident investigation, facility inspection, job analysis, personal communication, selection and training, 'standards' in each work activity identified, measuring performance by standards and correcting performance by improving the existing programmes. This first domino may fall due to inadequate standards, programmes and follow up.

Basic Causes (origins) are (1) Personal factors lack of knowledge or skill, improper motivation and physical or mental problems and (2) Job factors inadequate work standards, design, maintenance, purchasing standards, abnormal usage etc. These basic causes are origin of substandard acts and conditions and failure to identify them permits the second domino to fall, which initiates the possibility of further chain reaction. Immediate causes are only symptoms of the underlying problem. They are substandard' practices or conditions (known I as unsafe acts and unsafe conditions) that could cause the fourth domino to fall. These causes should be identified, classified and removed by appropriate measures.

Accident or incident is the result of unsafe acts or/and unsafe conditions. This point is the contact stage. Some counter measures employed are deflection, dilution, reinforcement, surface modification, segregation, barricading, protection, absorption, shielding etc. Injury includes traumatic injury, diseases and adverse mental neurological or systemic effects resulting from workplace exposures. 'Damage' includes all types of property damage including fire. The severity of losses involving physical harm and property damage can be minimized by prompt reparative action, salvage in the case of property damage and fire control devices and trained personnel.

Figure #4: Bird’s Accident Analysis (Frank E Bird, in 1969, analyzed 1753498 accidents reported by 297 companies of America) Inference of this 1-10-30-600 ratio is that 630 no injury accidents, with 10 minor and I major (serious) injury accidents, provide a much larger basis for many opportunities to prevent any injury accident. Out of total 641 events, only 10 may result in minor injuries and only 1 in major injury. But this can happen at any time not necessarily at the end as explained in the above domino updated theory. How Bird’s Dominos theory updates Heinrich Domino’s theory? Explain.

b. Human Factors Theory (Ferrel’s Theory)
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 is actually broad categories that contain several more specific causes. Improper activities are perhaps the simplest of the concepts, as it encompasses two straightforward 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 stresses 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. Which theory says “Causes of accidents: overload, incompatibility and improper activities of human” and how? c. Peterson’s Accident/Incident Theory 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, 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.

Figure #5: Human Factor Analysis 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. How Peterson differentiated his “Accident / Incident Theory” from “Human Factors Theory”? d.Epidemiological Theory Suchman stated epidemiological definition of accident as "An unexpected; unavoidable, unintentional act resulting from the interaction of host (accident victim), agent (injury deliverer) and environmental factors within situations which involve risk taking and perception of danger". This originated from the study of epidemics. Casual association between diseases or other biological processes (accidents) and specific environment are studied. A classic example of epidemiological method was given by Snow who discovered that persons using a particular water supply had a higher death rate from cholera than others. Gordon and McFarland supported that accidental injuries could be studied with the same techniques. Thus far, the chapter has focused on theories of accident causation. Each theory, while perhaps built upon some anecdotal observations or one or two established relationships, is by

definition highly theoretical. In other words, each is one person’s best guess as to what is occurring. The purpose is to explain some sort of correlations that have observed (statistically or anecdotally). The epidemiological approach is different from these theories. Rather than take a little data and try to formulate a theory, the epidemiological approach continually relies on collecting additional information to expand our knowledge. Explain: Accident Theory based on the Epidemics.

e. Systems Theory Model Most of the theories thus far discussed focus on human errors and environmental flaws. A systems model theory approaches the relationship between persons and their environments differently. Rather than the environment being full of hazards and a person being error prone, a system model view sees a harmony between man, machine, and environment. Under normal circumstances, the chances of an accident are very low. If someone or something disrupts the harmony by changing one of the components or the relationships between the three, the probability of an accident occurring increases substantially.

Figure #6: System Model

This necessitates the introduction of feedback system (as shown in diagram) to find out the faults/ causes in man, machinery and environment. The information that the man possesses can be strengthened through training. The stressors can be precedent in the following form –

1. 2.

Psychological stressors Environmental stressors.

Anxiety, aggressiveness, fatigue. Glare, temperature extremes and low levels of illumination, also includes 'Machine stressors' like unguarded machines at the point of operation, transmission of power and other dangerous parts. Narcotics & Alcohol.

3.

Physiological stressors

Table #1: Types of Stresses Factors Another aspect of the systems model is what is referred to as risk-taking. Whenever someone chooses to do something, there is an associated risk (Firenze, 1978). Smaller tasks and risks are often calculated on an unconscious level. For example, when one chooses to drive to work each morning, that person weighs the risks (slight chance of being in a car accident) and the benefits (making a living) and decides the benefits outweigh the risks. This hedonistic calculus, as with Petersen’s model, is quite similar to the rational choice perspective. Just as potential criminals may weigh the risks of being caught and managers, safety specialists & supervisors consider the chances of injury or financial loss. The decision to move forward with the task is only taken when it is decided the potential benefits outweigh the potential loss. In a real life example of this type of risk taking behavior Firenze (1978) suggests considering five calculated risks and benefits: 1) Job requirements 2) The capabilities and limitations of the worker in relation to her or her job 3) The potential gain upon succeeding 4) The potential consequences upon failure 5) The potential loss of not attempting the task Table #2: Firenze’s Five Calculated Risks and Benefits Additional information about these five factors becomes available through feedback after an initial attempt. In other words, a common task previously taken has well known risks and benefits, while a new task often has more unknown factors. What are the Two Aspects of System Model? Explain f. Swiss Cheese Model of Loss

Reason hypothesizes that most accidents can be traced to one or more of four levels of failure: Organizational influences, unsafe supervision, preconditions for unsafe acts, and the unsafe acts themselves. In the Swiss Cheese model, an organization's defences against failure are modelled as a series of barriers, represented as slices of Swiss cheese. The holes in the cheese slices represent individual weaknesses in individual parts of the system, and are continually varying in size and position in all slices. The system as a whole produces failures when all of the holes in each of the slices momentarily align, permitting (in Reason's words) "a trajectory of accident opportunity", so that a hazard passes through all of the holes in all of the defences, leading to a failure.

Figure #7: Swiss Cheese Model of Losses The Swiss Cheese model includes, in the causal sequence of human failures that leads to an accident or an error, both active failures and latent failures. The former concept of active failures encompasses the unsafe acts that can be directly linked to an accident, such as (in the case of aircraft accidents) pilot errors. The latter concept of latent failures is particularly useful in the process of aircraft accident investigation, since it encourages the study of contributory factors in the system that may have lain dormant for a long time (days, weeks, or months) until they finally contributed to the accident. Latent failures span the first three levels of failure in Reason's model. Preconditions for unsafe acts include fatigued air crew or improper communications practices. Unsafe supervision encompasses such things as, for example, two inexperienced pilots being paired together and sent on a flight into known adverse weather at night. Organizational influences encompass such things as reduction in expenditure on pilot training in times of financial austerity. What is Swiss cheese Model of Accident causation? Explain g. Energy Release Theory

Dr. Leslie Ball, former Director of Safety for NASA, introduced a causation theory. His thesis is that all accidents are caused by hazard, and all hazards involve energy, either due to involvement with destructive energy sources or due to a lack of critical energy needs. This model is most useful to identify hazards and to understand system safety.

Gibson noted that injury to a living organism can be only by some energy interchange. Hence it was suggested that the energy exchange should be considered as the injury agent. The energy exchange resulting in an injury could be mechanical, chemical, thermal, electrical etc. This concept is useful in understanding the way injury caused and examining the solutions. When a grinding wheel is in stop-position it does not make accident, but if it runs and fingers trapped, it makes accident because of its kinetic energy. William Hadden, 1970, explained 'energy transfer or release' as the main factor for accident causation and said that accidents and injuries are caused because of transfer or release of energy between objects, events or environment interacting with people. Ten strategies were suggested by Hadden to prevent or reduce losses as under: 1. blasting. 2. Reduce the amount of energy trailer, i.e. drive vehicle or machine at slow speed, reduce Prevent the transfer or origin of energy, e.g. safe substitution - using toluene instead of

benzene, not keeping the car running, dipping instead of spraying, shot blasting instead of sand

quantity or concentration 'of hazardous chemicals. 3. Prevent release of energy, e.g. flameproof electric fitting in flammable area, fall arrester

device, dyke to stop spread of .chemical, safe overflow pipe or level cut off device. 4. Change the rate of release or distribution of released energy, e.g. reduce the road slope,

use inhibitor to reduce rate of reaction, sprinkler to reduce rate of burning, scrubber to scrub toxic gas, condenser to liquefy organic vapour. 5. Divert (separate) the energy released in time or space, e.g. separate paths for vehicles and

pedestrian traffic, keep electric wiring or pesticide out of reach, and discharge gases at height 6. Provide barrier between the energy released and a structure or a person likely to be affected,

eg. guards on machines, radiation shield, filter, safety goggles, earplugs, insulation on hot surface, blast wall against explosion energy etc.

7.

Make the surfaces of structure safe. e.g. rounded corners, blunt objects, big handles of

tools and no sharp edges. 8. Strengthen the structure or person susceptible to damage, e.g. fire resistant wall, training

to workers and vaccination for disease. 9. Early detection ,of damage and actuate counter effect, e.g. fire detectors with sprinklers,

high level alarm and tripping of feed pump, temperature alarm and starting of cooling system.

10.

Speedy measures to restore normal condition, e.g. rehabilitation of injured worker, repairing of a damaged machine or vehicle.

Energy Release Theory- Explain.

h.

Combination Model Much like other theories, each theory of accident causation does not explain every accident. Rather, each explains one possible cause of an accident. For example, the epidemiological approach fails to really explain why one thing causes an accident, just which it does. Heinrich’s domino theory similarly fails to account for an environment, outside influences or chance. Each theory explains only a portion of accidents and all of these theories are incomplete. It is therefore important to recognize that true accident prevention, the reduction of the probability of accidents, can only occur when all possible causes are addressed. Focusing on only one or two theories is simply not enough. First, most theories and models agree that human error is always a possible cause of accidents. One of the simplest ways to address this is to avoid hiring accident-prone or shortsighted staff and dismiss those that have shown carelessness. This, however, only addresses human error by eliminating the extreme examples (people who show carelessness even before being hired) or after an accident has already occurred. A more effective strategy is to train employees carefully. Better safety training and increased knowledge of possible dangers can only decrease the chance of an accident occurring.

Figure #8: Combination of Theories Model

Second, socialization and subculture are also a common thread in accident causation. This further underscores the need for regular training and safety programs. A poor employee not only increases the risk of causing an accident, he or she can also corrupt future staff and make the problem grow exponentially. A safety awareness program is a good example of how to approach this problem. Regular meetings and positive safety posters are some of the tactics an awareness program can utilize. Keep employees motivated. The two-factor theory of motivation, also called the Motivator-Hygiene theory (Herzberg, Mausner & Snyderman, 1959), suggests that employees should be exposed to motivators (positive rewards) and hygiene factors (routine parts of a job, such as a good working environment, that prevent dissatisfaction). Management, whether involved in the awareness program or not, should also understand the importance of maintaining a positive subculture and be trained with intervention strategies for problem of employees.

Third, the physical environment is also an important aspect of accident causation that must be addressed. In addition to obvious implications (guard rails, safety warnings, hardhats, etc.), the subtle relationships between man and machine must also be considered. Ergonomic designs, often used to increase productivity, can also increase a worker’s comfort. Stress and boredom can play a role in human error, so keeping agitators to a minimum through ergonomic designs may also be helpful.

Finally, don’t rely solely on conventional thinking. Being proactive and using outside-the-box thinking can further a safety program substantially. Offering incentives and rewards to safetyoriented workers is a relatively new approach that, at minimum, gets attention. The status quo can also be challenged by simply asking if more can be done. An important part of any program is an evaluation to make sure it is working. Statistical analysis of accident rates, surveys of individuals’ perceptions of safety and inspections by safety specialists are all examples of potential indicators of program effectiveness. Triangulation (confirmation) of the findings by using multiple indicators is important to validate findings. If possible, different programs should be implemented within different environments so that effectiveness (or lack thereof) can be compared. If a program is not working, ask how it could be better. If it is working, ask the same. What Combination Theory of Accident Causation? Give note on its importance Accident /Incident Prevention.

II.

Interpretation of Causes in Accident / Incident Investigation & Prevention All above theories show some specific type of factors which are acting as initiating causes (See below list of factors). i. Human factors ii. Organizational factors iii. Environmental factors These causes contribute to common intermittent event which are known as unsafe act / unsafe condition. These unsafe acts or unsafe conditions finally lead to accident /incident in which injury or property damage or ill health or combination of these occur if they are not controlled in time. If we remove or rectify those unsafe acts and / unsafe conditions through the assessment of contributing causes, occurrences recurrences can definitely be prevented. All Accident / Incident approach have studied the same & common base event “Near Misses” which are considerably huge in numbers than accidents. This indicates that the causes for Near Misses are ignored for some time which eventually leads to accident due to ignoring such causes without any control on them. Thus these causes initiate some series of events which lead mostly to incidents and at some point to accidents. Combination theories of Accidents / Incidents can be a suitable model / approach for any accident / incident investigations and taken corrective & preventive actions accordingly. The investigations of Incidents / Accidents have to pin point the unsafe acts / unsafe conditions prevailed in the scene and should identify & assess the possible causes contributed to the Accident with the help of Combination of Model Accidents / Incidents. At once, the causes assessed, the corrective & preventive actions are taken on the following basic steps. 1. 2. 3. Engineering Education Enforcement

Most Common Questions: What is Heinrich Dominos Theory? Explain. How Bird’s Dominos theory updates Heinrich Domino’s theory? Explain. Which theory says “Causes of accidents: overload, incompatibility and improper activities of human” and how? How Peterson differentiated his “Accident / Incident Theory” from “Human Factors Theory”? Explain: Accident Theory based on the Epidemics. What are the Two Aspects of System Model? Explain What is Swiss cheese Model of Accident causation? Explain Energy Release Theory- Explain. What Combination Theory of Accident Causation? Give note on its importance Accident /Incident Prevention.

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