Faculty of Chemical Engineering

Universiti Teknologi MARA

Theories of

Process Safety - CPE615

Accident Causation
What Have you learned
so far……..???

• Hazard

UiTM
HASNORA JAFRI
• Risk
• Categories of Hazard
• Safety versus Health
• Acute versus Chronic
• Engineers and Safety
Incident versus Accident

• Incident: all undesired circumstances that have the

potential to cause accidents.
• Accident: a sequence of events that produce

UiTM
HASNORA JAFRI
unintended injury, damage to property or the
environment, production losses, or increased
liabilities.
• Accident refers to the event, not the results of the
event.
Near Miss……..
• an unplanned event that did
not result in injury, illness, or
damage – but had the

UiTM
HASNORA JAFRI
potential to do so.
• another term for this event:
“close call”
Accident Pyramids

1
1 Major
Accident

UiTM
HASNORA JAFRI
Major
Injury 10
Minor
29 Accident
Minor 30
Injury
Property Damage
300 Accidents
Incidents
(near miss)
600
Near miss

H.W. Heinrich (1931) Frank E. Bird Jr (1969)

 Harm to personnel, plant or environment

Failure to avoid Failure to mitigate or

Significant events Prevent escalation of events

UiTM
HASNORA JAFRI
Plant in dangerous Failure to control
state situation

Immediate causes of failure or disturbance

Root causes of failure or disturbances

F
F igure 2 – Tree showing the development of an accident (Wells,
1996)
Key Questions
• Why do accidents occur?
• How do accidents occur?

UiTM
HASNORA JAFRI
• What must we do to keep them from
happening?
Why do accidents occur?

• We choose to handle dangerous processes,

materials, energies
• To make a living

UiTM
HASNORA JAFRI
• To provide society with desirable products
• As long as we choose to handle them, a potential
for loss events exist.

Things can be done to reduce their likelihood

and severity to negligible or tolerable levels.
How do accidents occur?
• There are several theories that attempt
to explain the occurrence of accidents.
• Most widely used theories of accident

UiTM
HASNORA JAFRI
causation:
▪ Domino theory
▪ Human factors theory
▪ Accident/incident theory
▪ Sociotechnical system framework
1) Domino Theory
• Herbert W. Heinrich, an early pioneer of accident
prevention and industrial safety.
• He studied 75,000 reports of accidents for
insurance claims and concluded:

UiTM
HASNORA JAFRI
▪ 88% of industrial accidents are caused
by unsafe acts committed by workers
▪ 10% of industrial accidents
are caused by unsafe
conditions
▪ 2% of industrial accidents
are unavoidable.
Heinrich’s Axiom of Industrial
Safety
• Injuries result from a complete series of factors,
one of which is the accident itself

UiTM
HASNORA JAFRI
• An accident can occur as a result of unsafe act
and/or unsafe conditions
• Most accidents are the result of unsafe behaviour
by people
• An unsafe act or an unsafe conditions does not
immediately result in an accident/injury;
Heinrich’s Axiom of Industrial
Safety
• The reasons why people commit unsafe acts can
serve as helpful guides in selecting corrective

UiTM
HASNORA JAFRI
actions.
• The severity of an accident is largely fortuitous and
the factors that cause it are largely preventable.
• The prevention techniques are analogous with the
best quality and productivity techniques.
Heinrich’s Axiom of Industrial
Safety
• Management should assume responsibility for
safety because it is in the best position to get

UiTM
HASNORA JAFRI
results.
• The supervisor is the key person in the prevention
of industrial accidents.
• In addition to the direct costs of an accident (i.e.
compensation, liability claims, medical costs, and
hospital expenses) there are also hidden or indirect
costs.
 5 factors in the sequence of
events leading up to an accident

UiTM
HASNORA JAFRI
Social Fault of Unsafe Act
Environment Person or Accident Injury
and Ancestry (Carelessness) Condition
5 factors in the sequence of
events leading up to an accident
• Ancestry and social environment
▪ Negative character traits that might lead people to

UiTM
HASNORA JAFRI
behave in an unsafe manner can be inherited or
acquired as a result of the social environment.
• Fault of a person
▪ Negative character traits, whether inherited or
acquired, are why people behave in unsafe manner
and why hazardous conditions exist.
5 factors in the sequence of
events leading up to an accident

• Unsafe act/Unsafe conditions

UiTM
HASNORA JAFRI
▪ Unsafe acts committed by people
▪ Unsafe conditions due to the presence of
mechanical/physical hazards
• Accidents
• Injury
 Heinrich’s theory has two
central points:

• Injuries are caused by the action of preceding

UiTM
HASNORA JAFRI
factors

• Removal of the central factor (unsafe

acts/hazardous conditions) negates the action
of the preceding factors and, in so doing,
prevents accidents and injuries.
Removal of unsafe acts/unsafe
conditions prevents the accident

UiTM
HASNORA JAFRI
Injury

Accident

Unsafe act/unsafe condition

Fault of a person

Ancestry and social environment

2) Human Factors Theory

Attributes accidents to a chain of events that

were ultimately the result of human error.

UiTM
HASNORA JAFRI
Overload

Inappropriate Inappropriate
activities response
Overload
• An imbalance between a person’s capacity at any
given time and the load that a person is carrying in
a given state.

UiTM
HASNORA JAFRI
• A person’s capacity is the
product of such factors
as his/her ability,
training, state of mind,
fatigue, stress, and
physical conditions.
Overload

• Added burden resulting

from
▪ Environmental factors

UiTM
HASNORA JAFRI
(noise, distractions, etc.);
▪ Situational factors (level of
risks, unclear instructions,
etc.); and
▪ Internal factors (personal
problems, emotional stress,
worry, etc.)
Inappropriate Response
• How a person responds in a given situation can
cause or prevent an accident.
• Inappropriate response include:

UiTM
HASNORA JAFRI
▪ A person detects a hazardous condition but does nothing
to correct it;
▪ A person removes a safeguard from a machine in an
effort to increase output; or
▪ A person disregards an established safety procedure
• Such responses can lead to accidents.
 Inappropriate Activities

• Examples of inappropriate
activities include:

UiTM
HASNORA JAFRI
▪ A person undertaking a task he or
she doesn’t know how to do
(performing tasks without requisite
training)
▪ A person misjudging the degree of
risk involved in a given task and
proceeding based on that
misjudgment.
 Human Factors
Theory

Overload Inappropriate Inappropriate

UiTM
HASNORA JAFRI
Response Activities
•Environmental
factors •Performing task
•Internal Factors •Detecting hazard but
not correcting it without the
•Situational Factors requisite training
•Removing safeguards
from machines & •Misjudging the
equipment degree of risk
•Ignoring safety involved with a given
tasks
3) Accident/Incident Theory
• Extension of the human factors theory, developed
by Dan Petersen.
• Introduced such new elements as ergonomic traps,

UiTM
HASNORA JAFRI
the decision to err, and system failure.
• In this model, overload, ergonomic traps and
decision to err lead to human error.
• The system failure is an important contribution of
Petersen’s theory.
Some ways that a system fails -
Petersen
• Management does not establish a comprehensive
safety policy.
• Responsibility and authority with regard to safety

UiTM
HASNORA JAFRI
are not clearly defined.
• Safety procedures such as measurement,
inspection, correction and investigation are
ignored or given insufficient attention.
• Employees do not receive proper orientation.
• Employees are not given sufficient safety training.
 Petersen’s Accident/Incident Theory

Overload Ergonomics Decisions to

Traps err
•Pressure
•Fatigue •Incompatible •Misjudgment of
•Motivation workstation the risk
•Drugs

UiTM
HASNORA JAFRI
•Incompatible •Unconscious
•Alcohol expectation desire to err
•Worry

Human Error

System failure

•Policy Accident
•Responsibility
•Training
•Inspection
•Corrections
Injury/ Damage
•Standards
4) The sociotechnical framework

• Every fault in an incident scenario will have been

affected by root causes.

UiTM
HASNORA JAFRI
• Failures in large industrial system cannot be
considered solely in technical terms.
• The sociotechnical system approach emphasises
the individual, organisational, management and
technical aspects which affect a system’s
performance.
The sociotechnical framework

UiTM
HASNORA JAFRI
Immediate and Root Causes of
Accident

Immediate Cause

UiTM
HASNORA JAFRI
• The most apparent cause
• Represent the initiators of the incidents
• It is the symptom
• Normally called unsafe acts or unsafe conditions
Immediate Accident Causation

➢Unsafe acts
 Horseplay.
 Defeating safety devices.
 Failure to secure or warn.


UiTM
HASNORA JAFRI
Operating without authority.
 Working on moving equipment.
 Taking an unsafe position or posture.
 Operating or working at an unsafe speed.
 Unsafe loading, placing, mixing, combining.
 Failure to use personal protective equipment.
ACCIDENT
Immediate CAUSATION
Accident Causation
➢ Unsafe Conditions (Environmental)
 Improper PPE. (Personal Protective Equipment)
 Improper tools.
 Improper guarding.

UiTM
HASNORA JAFRI
 Poor housekeeping.
 Improper ventilation.
 Defective equipment.
 Improper illumination.
 Unsafe dress or apparel.
 Hazardous arrangement.
Root Cause of Accident
• Exists because of lack of management control
(commitment to safety policy, planning, organising,
etc.)
• Either personal related – lack of

UiTM
HASNORA JAFRI
knowledge or skills, poor
motivation, and physical
difficulties; or
• Job related – inadequate work
standards, poor maintenance or
design of equipment
Root causes examples (Wentz, 1998)

• Safety policy not defined and communicated

• Responsibility, authority, and accountability not assigned
• Emphasis on production, rather on safety
• Lack of direct communication with management

UiTM
HASNORA JAFRI
• Unsafe design and selection of equipment, chemicals, process
and facilities
• Inadequate safety inspection procedures
• Insufficient procedures for normal and emergency situations
• Lack of training
• Inadequate employee selection, supervision and rewards
 The “Accident Weed”
Hazardous Hazardous
Conditions Practices
Missing guard Horseplay

Poor housekeeping Ignored safety rules

Defective tools Didn’t follow procedures

Equipment failure
Did not report hazard

UiTM
HASNORA JAFRI
No MSDS’s Don’t know how

Purchasing unsafe equipment

Poor work procedures
Lack of supervision
No follow-up/feedback
Rules not enforced
Lack of Training
Lack of safety leadership
Poor safety management Poor safety leadership

Root Causes
 Discovery and correction of underlying/root
causes is very important to accident prevention
since if not corrected they will be repeated.

UiTM
HASNORA JAFRI
Accidents are expensive

“PREVENTION IS BETTER AND CHEAPER THAN CURE”

UiTM
HASNORA JAFRI
Direct cost of accidents (Brauer, 2005)

• Expenses incurred because of an accident

• Typically include medical expenses and compensation paid to
an injured employee for time away from work
• Costs for repair and replacement of damaged items

UiTM
HASNORA JAFRI
Indirect cost of accidents (Brauer, 2005)

• Are real expenses associated with accident, e.g

• Lost time of injured employee
• Time lost by other employees to assist injured
coworker

UiTM
HASNORA JAFRI
• Time lost by supervisor to investigate accident,
prepare report, and make adjustment of work
arrangements
• Time spent by company first aid, medical staff
• Lost of profit
• Paper works for insurance claim
• Production losses
References
• Brauer, L. (2005), Safety and Health for
Engineers, 2nd Edition, Wiley:Interscience
• Wells, G. (1996), Hazard Identification and Risk
Assessment, Rugby: IChemE

UiTM
HASNORA JAFRI
• Wentz, C. A. (1998). Safety, Health and
Environmental Protection. New York: McGraw
Hill.
Past Exam Question
A large storage tank was being field with flammable liquid but the
operators did not know that the level indication and the safety alarms
system had failed. They did not monitor the filling operation closely as
they believed that the tank still had plenty of capacity remaining. Later
in the evening the tank began to overflow. It was not detected until a
security guard noticed a strong odour. He immediately notified the

Process Safety - CPE615

operation personnel. The operators, however, did not take the report
seriously and respond promptly as the security guard was new on the
job. Later two operators responded by driving a truck to the area to
investigate.

Within minutes there were a loud explosion and fire. It was believed
that the truck provided the ignition source that cause the deflagration
and ensuing fires. It took a day and half for plant and civic personnel
to put out the fires that moved from one tank to another. More than a
dozen of employees were injured and hospitalised and there was a
significant property damage.
Past Exam Question
a) Describe the immediate cause of the accident
b) Describe the root cause of the accident
The immediate causes:
▪ Tank overfill

Process Safety - CPE615

▪ Operator did not monitor the filling process closely
▪ Driving a truck into a process area
▪ Faulty level alarms
The root causes:
▪ Lack of administrative procedures
▪ Level indicator and safety alarms were not well maintained and
inspected.
▪ Operators lack of knowledge due to a poor training program
▪ Behavioural problem (recklessness)
What must we do to keep
accident from happening…?

• Design of process
• Management of process

Process Safety - CPE615

• Operation of process
• Regulations

You will learn about these things in this course !

 For Next Tutorial Class
▪ Prepare a simple presentation or a video in less than
10 minutes to describe about one past industrial
accident.

Process Safety - CPE615

▪ Describe the root and immediate causes of the
accident
▪ Explain the possible prevention action that could be
taken