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MUARC - Accident Causation Analysis
MUARC - Accident Causation Analysis
au/muarc
Dr Paul Salmon
Ms Amy Williamson
Ms Eve Mitsopoulos-Rubens
Dr Christina Rudin-Brown
Dr Michael Lenne
Content
Human Factors
the scientific study of the relationship between man and
his working environment (Murell, 1965)
Accidents
Human error
Theoretical perspectives
1955 2005
Law s Regulators ,
Associations
R egulations
Changing market
Company conditions and financial
pressure
C ompany
Policy
Management
Changing competency
levels and education
Plans
Staff
Fast pace of
Action
Work technological change
Hazardous process
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Assistant bosuns
failure to shut
bow doors
Fatigue
Captains leaves
Negative port with bow
Choppy
reporting culture Doors open
sea
Not my job
Culture
Failure to install bow
Door indicator
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Figure showing the paths between the categories across the four HFACS levels ; Bold lines denote associations that
are highly statistically significant (p<.005), while dashed lines represent associations at the conventional level of
significance (p<.05). All associations represent positive correlations , aside from that between physical environment
and violations , which is negative
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Aim
UNSAFE SUPERVISION
Unsafe
supervision
PRE -CONDITIONS FOR UNSAFE ACTS
Organisational
influences
Physical T echnological Crew Personnel
environm ent environm ent resource readiness
m anagem ent
Resource Organisational Organisational
m anagem ent clm
i ate process
Adverse Adverse Physical &
m ental physiool gical m ental
states states m
il tiations
UNSAFE ACTS
UNSAFE
ACTS
Errors Violations
Example output
Jenkins, D. P., Salmon, P. M., Stanton, N. A., & Walker, G. H. (In Press). A systemic approach to accident analysis: a
case study of the Stockwell shooting. Ergonomics
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Ripswing incident
Ripswing incident
Company I nadequate Com pany Inadequate Fail ure t o s upervis e F ai lure of Devon S outhway s taff LE A check lis t not
management s afety employed emergenc y cent re manager to Count y Council to failure to follow s taff us ed by Southway
Lo ca l ar ea Go ve rnm en t procedures ins truct ors without
ignored lett er proc edures ens ure canoeing ins pec t cent re handbook f or in planning of t rip
p la nn in g & b ud ge tin g, regarding poor rec om mended was being s afely rec reat ional
C omp a ny ma na g eme n t s afety procedures BCU qualific ations t aught by centre ac tiv iti es
Teacher Delayed,
given c anoe Coc kpit s Abandonment
Teacher Inabilit y to right Groups s wept I nadequate
unsuitable fi lled with of c anoes searc h and
c apsiz es c aps ized out t o s ea
f or nov ices water
Phy sica l p roc esse s & a cto r c ont inual ly k ayak resc ue operation
acti vitie s
Students /t eac hers Los s of contac t Capsiz e of Fai lure to
Raft ing
inexperienc e of between fl ooded init iat e in-wat er Drownings
S tudent t oget her of
operating c anoes groups c anoes procedures
c aps iz ed group
Company I nadequate Com pany Inadequate Fail ure t o s upervis e F ai lure of Devon S outhway s taff LE A check lis t not
management s afety employed emergenc y cent re manager to Count y Council to failure to follow s taff us ed by Southway
Lo ca l ar ea Go ve rnm en t procedures ins truct ors without
ignored lett er proc edures ens ure canoeing ins pec t cent re handbook f or in planning of t rip
p la nn in g & b ud ge tin g, regarding poor rec om mended was being s afely rec reat ional
C omp a ny ma na g eme n t s afety procedures BCU qualific ations t aught by centre ac tiv iti es
Teacher Delayed,
given c anoe Coc kpit s Abandonment
Teacher Inabilit y to right Groups s wept I nadequate
unsuitable fi lled with of c anoes searc h and
c apsiz es c aps ized out t o s ea
f or nov ices water
Phy sica l p roc esse s & a cto r c ont inual ly k ayak resc ue operation
acti vitie s
Students /t eac hers Los s of contac t Capsiz e of Fai lure to
Raft ing
inexperienc e of between fl ooded init iat e in-wat er Drownings
S tudent t oget her of
operating c anoes groups c anoes procedures
c aps iz ed group
ACTIVITY/DEVICE FAILURE TO
LACK OF FAILURE TO IDENTIFY UNSAFE VOLUNTARY
Regulatory bodies & OVERLOOKED
associations REGULATORY BODY INSPECT CENTRE PRACTICE SCHEME ONLY
IN STANDARDS
FAILURE TO INADEQUATE
CULTURE
Local area Government ASSESS RISKS SUPERVISION
planning & budgeting , INADEQUATE INAPPROPRIATE FAILURE TO COMPLY
Company management
PROCEDURES RECRUITMENT WITH LEGISLATION FAILURE TO RESPOND
FAILURE TO RESPOND
TO REGULATORY BODY
TO SAFETY CONCERNS
REQUESTS
INADEQUATELY INAPPROPRIATE FAILURE TO POOR SITUATION INADEQUATE POOR
Technical & operational QUALIFIED ACTIVIITY CHECK WEATHER AWARENESS TRAINING COMMS
management
FAILURE TO COMPLY
INEXPERIENCE VIOLATIONS
WITH LAW, PROCEDURES
FAILURE TO
SKILL-BASED DECISION VIOLATIONS WRONG POOR ACTION MISTAKE
Physical processes & actor FOLLOW
activities ERRORS ERRORS ACTION COMMS TOO LATE
PROCEDURES
LAPSE INEXPERIENCE
UNSAFE EQUIPMENT
INAPPROPRIATE DESIGN FAILURE
Equipment & surroundings
INAPPROPRIATE EQUIPMENT
USE OF NO FAIL SAFE
EQUIPMENT NOT PROVIDED
EQUIPMENT UNSAFE ENVIRONMENTAL
EQUIPMENT CONDITIONS
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Data challenges
Data challenges
Feasibility study?
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Benefits
Questions?
paul.salmon@muarc.monash.edu.au