INCIDENT AND ACCIDENT THEORIES

- a number of theories about incidents and

accidents.

- The theories give us insight into preventive

actions.

- None is totally adequate, either at describing all t

he factors that contribute to the occurrence of
incidents or at predicting with reasonable accuracy
the likelihood that an incident will take place.

- People will find some theories more helpful than

others in preventing incidents.
 Domino Theory

An early theory (still in use by some) is the DOMINO

THEORY OF W. F. HEINRICH.

The theory states that an incident sequence is like a

series of five dominos standing on end. One can knock
others over.

The five dominos in reverse sequence are (1) an injury

caused by (2) an incident, which, in turn, is caused by
(3) unsafe acts or conditions. The latter are caused by
(4) undesirable traits (such as recklessness,
nervousness, violent temper, lack of knowledge, or
unsafe practices) that are inherited or
developed through one’s (5) social environment.
The incident sequence can be stopped by removing or
controlling contributing factors.

The theory places strong emphasis for incident

prevention on the middle domino: unsafe acts and unsafe
conditions.

Heinrich believed that unsafe acts are more frequently

involved in incidents than unsafe conditions. Therefore, his
philosophy of incident prevention emphasized unsafe acts
and person-related factors leading up to them. Individuals
involved in prevention of incidents may find some value in
this theory.

For engineers who do not have control over unsafe acts as

much as unsafe conditions, portions of this theory are of
limited value.
 Multiple Factor Theories

theory for incidents in which incidents are deemed to be

caused by many factors acting together.

The immediate cause may be an unsafe act or an unsafe

condition acting alone. In multiple causation theories, factors
combine in random or other fashion and cause incidents.

multiple factor model referred to as the four Ms:

MAN, MACHINE, MEDIA, AND MANAGEMENT

 Four system safety factors: the four Ms.

Man refers to people. Machine refers to any kind of equipment or vehicle. Media
includes such things as environments, roadways, and weather. Management is the
human context in which the other three Ms exist and operate.
The factors included in each multiple factor theory vary. In each multiple factor
theory, characteristics of the factors that may be involved in a particular incident are
identified.

For example,

characteristics of man are age, height, gender, skill level, amount of

training, strength, posture, motivation, emotional state, and so on.

Characteristics of media could include thermal conditions in buildings, water or snow

on a roadway, fresh water compared with salt water or a contaminant in air.

Characteristics of management might be management style, organizational structure,

communication flow, policies, and procedures.

Characteristics of machines might include size, weight, shape, energy source, type of
action or motion, availability or placement of controls, and materials of construction.
Multiple factor theories are useful in incident prevention.

They help identify which characteristics or factors are involved in

a given operation or activity.

Characteristics can be analyzed to see which combinations are

most likely to cause an incident or result in losses.

Statistical techniques, such as factor analysis, multiple regression

analysis, and other multivariate methods, may be used in
analyzing characteristics
 Energy Theory

William Haddon proposed the idea that many accidents and

injuries involve the transfer of energy.

Objects, events, or environments interacting with people

illustrate this idea: fires, hurricanes, projectiles, motor vehicles,
various forms of radiation, and other items produce injuries
and illnesses of various sorts.

The energy theory suggests that quantities of energy, means of

energy transfer, and rates of transfer are related to the kind and
severity of injuries.
the theory is called the energy release
theory, because the rate of release is an
important component.

This theory is attractive for many safety

engineering problems and suggests
ideas for controlling many unsafe
conditions.
Unlike Heinrich, who advocated a serial model, Haddon
argues for a parallel model of preventive action. A parallel
model includes multiple actions working at the same time.

A serial model has actions working one at a time. Haddon

notes there is no reason to select one preventive strategy
over another or to prioritize countermeasures according to
the accident sequence.

Any measure that prevents the damage or undesired result

is satisfactory.

There is one exception to this parallel model, the quantity

of energy involved. As the amount of energy increases,
countermeasure higher in the list are more desirable.
 Using energy transfer as the accident-injury model, Hadden
suggests 10 strategies for preventing or reducing losses.

1. Prevent the marshalling of energy.

In this strategy, the goal is not producing energy or changing it to a

form that cannot cause an accident or injury.

Examples are

Not producing gun powder, substituting a safe substance for a

dangerous one, preventing the accumulation of snow where
avalanches are possible, removing snow where slips and falls can
occur, not letting small children climb to levels above the floor,
and not setting a vehicle in motion.
 Using energy transfer as the accident-injury model, Hadden
suggests 10 strategies for preventing or reducing losses.

2. Reducing the amount of energy marshalled.

Examples are

keeping vehicle speeds down, reducing the quantities or

concentration of high energy or toxic materials, limiting the
height to which objects are raised, and reducing machine
speed to the minimum needed when a machine is unguarded
for cleaning or maintenance.
 Using energy transfer as the accident-injury model, Hadden
suggests 10 strategies for preventing or reducing losses.

3. Prevent the release of energy.

Examples are

using various means or devices to prevent elevators from

falling, flammables from igniting, or foundations from being
undercut by erosion.
 Using energy transfer as the accident-injury model, Hadden
suggests 10 strategies for preventing or reducing losses.

4. Modify the rate at which energy is released from its source

or modify the spatial distribution of the released energy.

Slowing the burning rate of a substance or using

an inhibitor and reducing the slope of roads are examples.
 Using energy transfer as the accident-injury model, Hadden
suggests 10 strategies for preventing or reducing losses.

5. Separate in space or time the energy being released from

the structure that can be damaged or the human who can be
injured.

Examples include separate paths for vehicular and pedestrian

traffic, placing electric power out of reach, using traffic
signals to phase pedestrian and vehicular traffic, and using
energy-absorbing materials.
 Using energy transfer as the accident-injury model, Hadden
suggests 10 strategies for preventing or reducing losses.

6. Separate the energy being released from a structure or

person that can suffer loss by interposing a barrier.

Safety glasses, barrier guards, radiation filters or shields,

median barriers on roadways, thermal insulation, and
explosive barricades are examples of barriers.
 Using energy transfer as the accident-injury model, Hadden
suggests 10 strategies for preventing or reducing losses.

7. Modify the surfaces of structures that come into contact

with people or other structures.

Rounded corners, blunt objects, dull edges, and larger

surface areas for tool handles are examples.
 Using energy transfer as the accident-injury model, Hadden
suggests 10 strategies for preventing or reducing losses.

8. Strengthen the structure or person susceptible to damage.

Examples for this strategy are fire and earthquake-resistant

construction of buildings, training of personnel,
and vaccination for disease.
 Using energy transfer as the accident-injury model, Hadden
suggests 10 strategies for preventing or reducing losses.

9. Detect damage quickly and counter its continuation or

extension.

Sprinklers that detect heat and spray water to prevent the

spread of a fire and wear indicators built into the treads of
vehicle tires are examples of this strategy
 Using energy transfer as the accident-injury model, Hadden
suggests 10 strategies for preventing or reducing losses.

10. During the period after damage and the return to normal
conditions, take measures to restore a stable condition.

Examples are rehabilitating an injured worker and

repairing a damaged vehicle.
 Errors in Management Systems

As part of their approach to management through quality, Juran and

Demming focused on work processes and the role management has in
establishing the processes provided for workers to follow.

Both focus on errors by workers as attributes of poor management

processes.

Deming claims that 85% of errors are the result of poor processes, and
no matter how hard someone tries to improve within a given process, it
is not possible unless there is a change in the process itself.
The focus is on management getting the process right,
reducing errors in poor processes, and avoiding the
need to correct things after they have resulted in
errors.

Errors are a management issue, not a worker issue.

Incidents and accidents are simply a form of error.

They interrupt processes and reduce quality. However,

by engaging both workers and managers together in
helping to get the processes right, all participants work
together to achieve quality (and safety).
Juran notes that critical processes, those which
present serious dangers to human life, health,
and the environment or which create losses of
very large sums of money, require planning and
design to reduce the opportunity for human error
to a minimum.

Similarly, reengineering concepts of Hammer

and Champy focus on improving business
processes, but rely on major redesign principles
and technological change to achieve operational
improvements and reduced errors
Quality improvement, six sigma,
and reengineering approaches
create an opportunity to reduce
incidents and losses by
improvements to the processes
used to accomplish work.
 Single-Factor Theories

Many individuals, particularly those not trained in incident

prevention and investigation,have the idea that there is a
single cause for an incident.

A single factor theory assumes that when one finds a

cause, there is nothing more to find out.

Single-factor theories have limited use in prevention,

because contributing factors and corresponding
corrective actions will be overlooked.

The single-factor theory is a very weak tool in the arsenal

of incident prevention and safety management. In fact, it
is often a hindrance.
 PREVENTIVE STRATEGIES

reactive approach

general approach for using data from incidents to

prevent them from occurring in the future.

Regardless of the theory and methods used, the

causes of incidents are identified and corrective
actions are taken to prevent future incidents of the
same type.

Different strategies are possible for this approach.

The strategies are based on frequency,

A reactive approach for deriving severity, and cost. Each has merit, depending on
preventive actions from preventive goals.
accidents.

The reactive approach requires that at least one

incident must occur to identify preventive actions.
 PREVENTIVE STRATEGIES

proactive approach

A proactive approach for developing

preventive actions before accidents occur.
 PREVENTIVE STRATEGIES

Different strategies possible for this approach

The strategies are based

on frequency, severity,
and cost.

Each has merit,

depending on preventive
goals
 Frequency

Frequency strategies try to prevent as many incidents as possible.

Therefore, investigation, analysis, and preventive actions are directed toward

incidents that occur frequently.

Preventive actions attempt to reduce the frequency of occurrence.

Recognition of these related factors will help direct preventive efforts where they
will be most effective.

For example, nearly 50% of injuries occur to workers in their firstyear on the job.
Half of these occur in the first three months. Centering corrective actions
(such as proper training) on new employees and their work environments should
reduce incident frequency more than would applying the effort with equal intensity
to all workers
 Severity

Another approach is directed at serious cases: those cases

involving long-term disability, long or serious illnesses, death, large
numbers of people, or large property loss.

One study reported that serious injuries occur most frequently in

four kinds of work activities: construction,nonproductive activities,
rarely performed and unusual nonroutine work and work involving
high health risks.

Data like these can help formulate strategies to prevent

serious injury and illness.
 Cost

Another strategy is to prevent high-cost incidents.

This strategy, based on the principle of Pareto’s law,

uses cost as the basis for measuring seriousness of
incident consequences,not the injury or illness itself.

Although cost and severity strategies are much the

same, a cost strategy includes losses other than
human ones.
 Combinations

Another strategy is to use a combination of frequency,

severity, and cost.

To establish priorities for preventive actions, one can use

a number of risk analyses and related techniques

They rely on the probability that an event will occur or the

frequency of its occurrence, the seriousness of the event if
it does occur, the cost of losses that could be avoided,
and the cost to implement corrections.
 The Three Es of Safety

Another concept for selecting

preventive actions can be structured
around the “three Es of safety”:
engineering, education, and
enforcement.
Engineering includes such actions as
substituting less hazardous materials, reducing
the inventory of hazardous materials,
modify processes, designing out hazards,
incorporating fail-safe devices, using warning
devices and prescribing protective equipment.
Education includes:

• training people in safe procedures and practices

• teaching people how to perform a job correctly and safely

• teaching users how to use a product safely

• teaching people what hazards exist in a product, process, or

task and how to take appropriate protective actions

• training engineers about hazard recognition, hazard

evaluation, compliance with

safety standards, and legal responsibilities

Enforcement is achieving compliance with federal,
state, and local laws and regulations,with consensus
standards and with company rules and procedures.

Sometimes a fourth E is part of the paradigm:

enthusiasm. It refers to motivating people in an
organization to cooperate with safety programs through
participation and other means. It is motivating users to
follow safe practices.
EXERCISES

1. Identify unsafe acts and unsafe conditions in the video.

2. Identify preventive actions that were possible for the cases from a domino
theory and energy theory perspective.

3. Identify factors involved in each case using a multiple factor theory, such as
the four Ms.