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LECTURE NOTES:
ACCIDENT AETIOLOGY
1.0
Accident causation models were originally developed in order to assist people who had to
investigate occupational accidents, so that such accidents could be investigated effectively.
Knowing how accidents are caused is also useful in a proactive sense in order to identify
what types of failures or errors generally cause accidents, and so action can be taken to
address these failures before they have the chance to occur.
The Domino Theory
In 1931, the late H.W. Heinrich (Heinrich et al, 1980 1) presented a set of theorems known as
the axioms of industrial safety. The first axiom dealt with accident causation, stating that
the occurrence of an injury invariably results from a complicated sequence of factors, the
last one of which being the accident itself.
Alongside, he presented a model known as the domino theory as this accident sequence
was likened to a row of dominoes knocking each other down in a row. The sequence is: Injury, caused by an;
Accident, due to an;
Unsafe act and/or mechanical or physical hazard, due to the;
Fault of the Person, caused by their;
Ancestry and Social Environment.
Heinrich HW, Peterson D & Roos N (1980), Industrial Accident Prevention, 5 th Edition, Mcgraw Hill,
New York
The accident is avoided, according to Heinrich, by removing one of the dominoes, normally
the middle one or unsafe act. This theory provided the foundation for accident prevention
measures aimed at preventing unsafe acts or unsafe conditions.
The first update of the Domino Theory was presented by Bird & Loftus [ Heinrich et al, 1980;
Bird & Germain, 19862]. This update introduced two new concepts;
The influence of management and managerial error;
Loss, as the result of an accident could be production losses, property damage or
wastage of other assets, as well as injuries.
This model (known as the International Loss Control Institute or ILCI model) is shown in the
figure below:
The domino model has been noted as a one-dimensional sequence of events. Accidents are
usually multi-factoral and develop through relatively lengthy sequences of changes and
errors. This has led to the principle of multiple causation.
According to Peterson 3(1978), behind every accident there lies many contributing factors,
causes and sub-causes. The theory of multiple causation is that these factors combine
together, in random fashion, causing accidents. So, during accident investigations, there is a
Bird FE & Germain GL (1986), Practical Loss Control Leadership, International Loss Control
need to identify as many of these causes as possible, rather than just one for each stage of
the domino sequence.
The accident model is in reality an amalgam of both the domino and multi-causality theories,
such as that shown below.
ROOT CAUSE
(Lack of Control)
cause a
cause b
cause c
BASIC CAUSE
cause d
cause e
IMMEDIATE
CAUSE
cause f
INCIDENT
LOSS
Conclusion
All accidents whether major or minor are caused, there is no such thing as an accidental
accident!!
Very few accidents, particularly in large organisations and complex technologies are
associated with a single cause.
2.0
Introduction
Although the role that human error plays in accident causation has been accepted for many
years, it is only recently that a lot of concerted effort has been put into detailed research into
human error in accidents.
During the past two decades the UK has suffered a large number of tragic disasters. These
include:
London Underground Fire at Kings Cross (1987)
31 people killed
Beyond the technical issues two common points emerged strongly from the inquiries into
these accidents, which are:
The influence of human error in the chain of events leading to the accident;
People can cause or contribute to accidents (or mitigate the consequences) in a number of
ways (HSE, 19995):
Through a failure a person can directly cause an accident. However, people tend not to
make such errors deliberately. We are often set up to fail by the way that our brain
Rimmington J (1993), Does Health and Safety Pay? Safety Management, September, p39-62
HSE (1999), Reducing Error and Influencing Behaviour, HS(G)48, HSE Books
processes information by our training, through the design of equipment and procedures
and even through the culture of the organisation that we work for.
People can make disastrous decisions even when they are aware of the risks. We can
also misinterpret a situation and act inappropriately as a result. Both of these can lead to
the escalation of an incident.
On the other hand we can intervene to stop potential accidents. Many companies have
their own anecdotes about recovery from a potential incident through the timely actions
of individuals. Mitigation of the possible effects of an incident can result from human
resourcefulness and ingenuity.
The degree of loss of life can be reduced by the emergency response of operators and
crew. Emergency planning and response including appropriate training can significantly
improve rescue situations.
We accept that human error is inevitable, shrug wer shoulders, tell him to be a bit more
careful and carry on as before with wer fingers crossed.
Alternatively, we can say as he was responsible, we should discipline him, perhaps even
sack him.
The third option is a half-way house whereby we give him the benefit of the doubt and
decide that he might need retraining. However, if all we have found out about the
accident was that he was the cause we have learnt nothing new on which to base the
retraining. We will almost certainly therefore be reduced to repeating the training which
we know has already failed!
Unfortunately this is a pretty reasonable description of the approach to human error in
accidents that has existed in most industrial organisations for years. If accidents are to be
prevented in the future it is no use whatsoever to blame people for their mistakes unless
we have a detailed understanding of what caused the mistakes. Only by understanding all
the issues which have caused (or could cause) an accident can we identify the way to
prevent future accidents
HSC (1993) Organising for Safety, 3 rd Report of the Human Factors Study Group of the Advisory
Department of Transport (1988), Investigation into the Kings Cross Underground Fire,
London:HMSO
Department of Transport (1987) The Herald of Free Enterprise Formal Report, London:HMSO
the attitude to safety of Senior Management. A serious concern with obviously horrendous
implications, had been raised by senior and experienced members of the staff which could
have been remedied at a relatively reasonable cost. More generally, the report into the
capsize draws the following conclusion:
Inquiry into the capsize of the Herald of Free Enterprise
All concerned in management, from the members of the Board of
Directors down to the junior superintendents, were guilty of fault in that
all must be regarded as sharing responsibility for the failure of
management. From the top to the bottom the body corporate was
infected with the disease of sloppiness.
By implication such a comment, like those quoted from the Kings Cross Report above, is
looking beyond the events which immediately preceded the accident and highlighting the
operational circumstances and managerial attitudes which, in effect, predisposed the critical
events.
Exactly the same point is made in the report of the inquiry into the Clapham Junction rail
crash9, in this case however the report emphasises the point much more specifically:
Inquiry into the Clapham Junction Rail Crash.
The direct cause of the Clapham Junction accident was undoubtedly
the wiring errors made by Mr. Hemmingway in his work in the Junction
A relay room.
Later, the report goes on to state...
The concept of absolute safety must be a gospel spread across the
whole workforce and paramount in the minds of management. The vital
importance of this concept .. was acknowledged time and again in the
evidence which the Court heard ...
But, subsequently it also states..
The concern for safety was permitted to co-exist with working practices
which ... were positively dangerous ... The best of intentions regarding
safe working practices was permitted to go hand in hand with the worst
of inaction in ensuring that such practices were put into effect.
This is an unequivocal statement that while the accident occurred as a result of specific
errors by a specific individual, the report considers that the likelihood of such errors was
Department of Transport (1988) Investigation into the Clapham Junction Railway Accident,
London:HMSO
increased considerably by the organisational and managerial framework in which his work
was conducted.
The above comments can all be summed up effectively by a quotation from the inquiry into
the Piper Alpha Oil rig fire10:
What then are the general conclusions which can be drawn from the above disasters which
are common to the various events while independent of the specific hazards and risks in
which the accidents occurred?
In essence they can be summarised as follows:
Not one of these organisations had, before the accidents, any serious reservations about
their safety procedures, organisation or management, yet there were clearly many
problems of which they were not aware.
Errors made at the sharp-end (the immediate causes of an accident) must be seen in
the wider context of the organisation and management climate in which they were
committed. Additionally more thought needs to be given to the design of systems and
equipment to minimise the potential for human error. Both of these issues need to be
given much more serious consideration if repeat (or similar) incidents are to be avoided.
Actions speak louder than words. The best of written safety policies, the most detailed
set of safety rules and procedures etc. are totally meaningless unless they are fully
resourced, rigorously implemented and kept under regular review.
Commitment, positive safety attitudes and motivation together with constant vigilance
throughout the organisation (but led from the top), are essential to high safety standards.
10
Department of Energy (1990) The Public Inquiry into the Piper Alpha Disaster, (2 vol),
London:HMSO
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3.0
The term human error is wide and can include a great variety of human behaviour.
Therefore, in attempting to define human error, different classification systems have been
developed to describe their nature. Identifying why these errors occur will ultimately assist in
reducing the likelihood of such errors occurring.
The distinction between the hands on operator errors and those made by other aspects of
the organisation have been described by Reason 11(1990) as active and latent failures.
Active Failures have an immediate consequence and are usually made by front-line people
such as drivers, control room and machine operators. These immediately preceed, and are
the direct cause, of the accident.
Latent failures are those aspects of the organisation which can immediately predispose
active failures. Common examples of latent failures include (HSE, 1999):
Ineffective training;
Inadequate supervision;
Latent failures are crucially important to accident prevention for two reasons:
1. If they are not resolved, the probability of repeat (or similar) accidents remains high
regardless of what other action is taken;
2. As one latent failure often influences several potential errors, removing latent failures can
be a very cost-effective route to accident prevention.
12
HSE (1999), Reducing Error and Influencing Behaviour, HS(G)48, HSE Books
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Human Failures
Violations
Human Errors
Routine
Mistakes
Skill-based errors
Situational
Rule-based
Slips of action
Exceptional
Knowledge-based
Lapses of memory
Slips and Lapses: These occur in routine tasks with operators who know the process well
and are experienced in their work:
They are action errors which occur whilst the task is being carried out;
They often involved missing a step out of a sequence or getting steps in the wrong order
and frequently arise from a lapse of attention;
Operating the wrong control through a lapse in attention or accidentally selecting the
wrong gear are typical examples.
Mistakes: These are inadvertent errors and occur when the elements of a task are being
considered by the operator.
They are decisions that are subsequently found to be wrong, although at the time the
operator would have believed them to be correct. There are two types of mistake (HSE,
1999), rule based and knowledge based:
Rule based mistakes occur when the operation in hand is governed by a series of rules.
The error occurs when an in appropriate action is tied to a particular event
Knowledge based errors occur in entirely novel situations when you are beyond your
skills, beyond the provision of the rules and you have to rely entirely on adapting your
basic knowledge and experience to deal with a new problem.
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Violations are any deliberate deviation from the rules, procedures, instructions and
regulations, which are deemed necessary for the safe or efficient
maintenance
of
plant
or
equipment.
Breaches
in
these
operation and
rules
could
be
accidental/unintentional or deliberate.
Violations occur for many reasons, and are seldom wilful acts of sabotage or vandalism. The
majority stem from a genuine desire to perform work satisfactorily given the constraints and
expectations that exist. Violations are divided into three categories: routine, situational and
exceptional (HSE,1999).
Routine Violations are ones where breaking the rule or procedure has become the normal
way of working. The violating behaviour is normally automatic and unconscious but the
violation is recognised as such, by the individual(s) if questioned. This can be due to cutting
corners, saving time. or be due to a belief that the rules are no longer applicable.
Situational Violations occur because of limitations in the employees immediate work space
or environment. These include the design and condition of the work area, time pressure,
number of staff, supervision, equipment availability, and design and factors outside the
organisations control, such as weather and time of day. These violations often occur when a
rule is impossible or extremely difficult to work to in a particular situation.
Exceptional Violations are violations that are rare and happen only in particular
circumstances, often when something goes wrong. They occur to a large extent at the
knowledge based level. The individual in attempting to solve a novel problem, violates a rule
to achieve the desired goal.
Latent Failures
Latent failures are the factors or circumstances within an organisation which increase the
likelihood of active failures. Consider some examples of latent failures in relation to the
example accidents given earlier:
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The existence of these, and other similar, latent failures within the London Underground
operation significantly increased the probability of a major escalator fire, with hindsight it was
almost a matter of when rather than whether. It is also apparent, as suggested above, that
unless the remedial action taken encompassed these organisational/management latent
failures, that a repeat event was likely for, quite simply, the major influencing factors would
have remained in place to predispose a similar event.
The Capsize of the Herald of Free Enterprise
among the latent failures involved here are the following:
It was impossible for anyone to on the bridge to see whether the bow doors had
been closed prior to setting sail and although there were organisational procedures
in place the Officer in charge was, effectively, working on the basis of faith rather
than any more positive feedback of information.
This design latent failure was compounded by the attitude of the senior management
in the memos in reply to a request for an on-bridge warning device (quoted earlier).
For a formal request concerning a major safety issue, from a senior operational
manager, to be treated in such a way clearly indicates that there was apparently very
little credibility given to potential safety issues.
Over 180 lives were lost largely as a result of latent failures by the ships designers who
overlooked, or ignored the potential implications of bridge officers not being able to be
certain that the bow doors were closed, compounded by the fact that senior management
also apparently considered the issue to be of little concern.
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Rules & Procedures: Rules and procedures provide the framework upon which safety
assurance is built and are claimed to be effective control measures. However this is little
more than an assumption rather than a proven reality. Studies have shown that safety rules
and procedures are often:
Written negatively, concentrating on should not be done rather than on what should
be done;
Impractical;
Training should concentrate on what is safe, rather than unsafe, what to do, rather
than what not to do.
Equipment design & Maintenance: limitations in the standard of ergonomics applied to the
design of the equipment/plant increase the risk of human error. Whilst it is usual to associate
design limitations with unintentional errors, i.e. slips & mistakes, poor designs also create a
strong motivation for operators to violate safe working procedures.
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Conclusion of Section
Human Error is more than operator/pilot error. Everyone can make errors no matter how
well trained and motivated they are.
It is useful to distinguish between active and latent failures. Active failures are those
hands on operator errors that immediately precede an accident. Latent failures are the
factors or circumstances within an organisation which increase the likelihood of active
failures. Latent failures lie hidden until they are triggered at some time in the future.
In the domino theory or chain described earlier in the course active failures are
analogous to the immediate cause and latent failures analogous to the underlying or root
cause.
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4.0
Reducing human error involves far more than taking disciplinary action against an individual.
There are a range of measures which are more effective controls including the design of the
equipment, job, procedures and training.
Human Failures
Violations
Human Errors
Routine
Mistakes
Skill-based errors
Situational
Rule-based
Slips of action
Exceptional
Knowledge-based
Lapses of memory
Switches which are too close and can be inadvertently switched on or off;
Displays which force the user to bend or stretch to read them properly;
Displays which are cluttered with non-essential information and are difficult to read.
Mistakes
Training, for individuals and teams, is the most effective way for reducing mistake type
human errors. The risk of this type of human error will be decreased if the trainee
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understands the need for and benefits from safe plans and actions rather than simply being
able to recite the steps parrot fashion. Training should be based on defined training needs
and objectives, and it should be evaluated to see if it has had the desired improvement in
performance.
Violations
There is no single best avenue for reducing the potential for deliberate deviations from safe
rules and procedures. The avenues for reducing the probability of violations should be
considered in terms of those which reduce an individuals motivation to violate. These
include:
Real or perceived pressure from the boss t adopt poor work practices;
Impractical procedures,
Ineffective training;
Inadequate supervision;
One of the principal ways of systematically doing this is through a health and safety
management system. This is the subject of the next topic area in this course.
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