OUTLINE

1. Accident Causation Theories/Models

2. Behaviour Based Safety
3. Accident Investigation
What is an accident? 1

 It’s
a consequence/outcome of the failure of human
or machine, or environment
 Unplanned event that results in mishap (personal
injury or property damage)

Act of God Human Error

ACCIDENT
Cost of doing
Business
 Theories of Accident Causation
1. General Models of the Accident Process
A. Sequential Models (Linear Chain of Events)
1. Domino Theory (Heinrich, 1939)
2. Updated Domino Theory (Heinrich et al., 1980)
3. Stair Step Model (Heinrich et al., 1980)
4. Stage Model (Goeller, 1968)
5. (Tree Models)
6. Event Trees (US NRC, 1975)
7. Fault Trees (Hammer, 1980)
8. Cause Trees (Driessen, 1970)
9. MORT (Johnson, 1975,198O)
10. (Network Models)
11. Multi-Linear Sequencing (Benner, 1975)
12. PERT-CPM (Grimaldi and Simonds, 1975)
B. Epidemiological Models
1. Host-Agent-Environment Model (Gordon, 1949)
2. Cohort Analysis (Waller, 1977)
3. Home Accident Model (Johnson, 1973)
4. Industrial Accident Model (Johnson, 1973)
5. Haddon Matrix (Haddon, 1975)
C. Energy Transfer Model
1. Energy Exchange (Gibson, 1961)
2. Energy Countermeasures (Haddon, 1975)
D. Systems Model (Surry, 1968)
1. P-Theory Model (Benner, 1975)
2. Change Analysis (Johnson, 1980)
3. Manual Control Theory (Rouse, 1980)
4. Car-Driver Model (Sheridan, 1976)
Mark Lehto and Gavriel Salvendy
Journal of Engineering and Technology Management,
1991
1
2. Models of Human Error and Unsafe Behavior 3. Models of the Mechanics of Human Injury
A. Behavioural Accident Models 1. Tool Use Trauma (Armstrong
1. Accident Proneness (Greenwood and Woods, et al., 1986; Tichauer, 1973)
1919) 2. CTD-123 (Burnette, 1989)
2. Personality Traits (Surry, 1968) 3. NIOSH Lifting Guide (NIOSH,
3. Life Change Unit Theory (Alkov, 1972) 1980)
4. Adjustment Stress Theory (Kerr, 1957) 4. Biomechanical Model
B. Human Decision Making Models (Chaffin, 1988)
1. Purposive Risk-Taking Model (Taylor, 1976) 5. MMH Model (Mital, 1983)
2. Risk Perception Model (Slavic et al., 1984; 6. Slip Resistance (Lehto and
Perusse, 1980) Miller, 1987)
3. Risk Acceptability Model (Litea et al., 1983) 7. Ladder Climbing (Bloswick
4. Heuristics and Biases (Tversky and Kahneman, et al., 1984)
1974,198l)
5. Expected Utility Model (Raiffa, 1968)
6. Signal Detection (Tanner and Swets, 1954)
7. Bayesian Inference (Winterfeldt and Edwards,
1986)
C. Human Information Processing Models
1. Single Channel Hypothesis (Welford, 1968)
2. Human Error Model (Wigglesworth, 1972;
Lawrence, 1974)
3. Decision Stage Model (Surry, 1968; Hale and
Hale, 1970; Andersson et al., 1978)
4. Communication Model (Lehto and Miller, 1986)
5. Warning Tree (Lehto and Miller, 1986)
6. Arousal/Effort/Attention (Kahneman, 1973)
7. Resource Allocation (Navon and Gopher, 1979;
Wickens, 1984)
8. Task Scheduling (Parks, 1979; Schmidt, 1978)
9. Levels of Performance (Rasmussen, 1983,1986)
10. GOMS (Card et al., 1983; Kieras, 1988)
D. Human Error Taxonomies
1. Data Store (Altman, 1964)
2. Error Mechanisms (Norman, 1983; Rasmussen,
1986)
3. Integrative Taxonomy (Rasmussen, 1982)
Theories of Accident Causation 1

 Random Event
 Proneness Theory
 Domino Theory
 Human Factors Theory
 Accident / Incident Theory
 Epidemiological Theory
 Systems Theory
 Combination Theory
 Behavior Based Theory
Consequences of Accidents

Direct Consequences Indirect Consequences

1. Human life 1. Loss of income

2. Personal injury 2. Medical expenses
3. Property damage 3. Time to replace another person
4. Decreased employee moral

FOR EVERY $1 OF DIRECT COSTS FOR INJURY/ILLNESS THERE ARE UP TO $100 OF INDIRECT COSTS
Heinrich’s Domino Theory 1

Engineering
Education
Enforcement

Social Fault of a Unsafe Act

Environment human or Accident Injury
and Ancestry (Carelessness) Condition

MISTAKES OF PEOPLE
Human Factors Theory of Causation 1

Attributes accidents to a chain of events that were ultimately the result of human error

Overload Inappropriate Inappropriate

Response Activities
Environmental
Factors (noise, Detecting a
Performing tasks
distractions hazard but not
without the
correcting it
Internal Factors requisite training
(personal problems, Removing
Misjudging the
emotional stress) safeguards from
degree of risk
machines and
Situational Factors involved with a
equipment
(unclear given task
instructions, risk Ignoring safety
level)
Human Factors Theory of Causation 1
 Overload
 Worker’s Capacity - Natural Ability, Training, State of Mind, Fatigue, Stress, Physical Condition
 Environmental Factors - Noise, Climatic, Lighting, Distractions, etc
 Internal Factors - Personal Problems, Emotional Stress, Worry
 Situational Factors - Level of Risk, Unclear Instructions, Novelty, etc
 Inappropriate Response
 Ignores a suspected hazard
 Disregards established safety procedures
 Circumvents safety devices
 Includes incompatibility with person’s workstation, size, required Force, Reach, Feel, etc
 Inappropriate Activity
 Performing tasks without requisite training
 Misjudging the degree of risk
Accident/Incident Theory 1

Overload Ergonomic Traps Decision to Err

Pressure Misjudgment of
Incompatible
Fatigue workstation (i.e. the risk
Motivation size, force, reach, Unconscious
feel) desire to err
Drugs
Incompatible Logical decision
Alcohol expectations based on the
Worry situation

Human Error
(response/action)
Systems Failure
Policy Inspection Accident
Responsibility Correction
Training Standards Injury/Damage
Epidemiological Theory of Causation 1
Study causal relationships between environmental factors and accident

Predisposition Situational
Characteristics Characteristics
Risk assessment by
Susceptibility of people individuals
Perceptions Peer pressure
Environmental factors Priorities of the
supervisor
Attitude

Can cause accident

Systems Theory of Causation 1

Machine Person Task to be

Collect Weigh Make
performed
information risks decision
Environment

Interaction

 System is a group of interacting and interrelated components that form a unified whole
 People, Machinery and Environment forms a system
 The likelihood of an accident occurring is determined by how these components interact
 Changes in the patterns of interaction can increase or decrease the probability of an
accident occurring
Combination Theory of Causation 1

 A single theory may not suit all circumstances

 For some accidents, a given model may be very accurate, for others less so
 Some theories address particular problems better than other theories
 A combination of theories & models may be the optimal approach
 Often the cause of an accident cannot be adequately explained by just one theory
 Actual cause may combine parts of several different models
Why Employees Engage in At-Risk 2
Behaviors
 “Nothing is going to happen to me” attitude
 Lack of awareness
 Perception that risk is low
 Jobs get done faster
 At-risk behavior is reinforced
Antecedents 2

 Prompt people to act

 Precede the behavior
 Communicate information
 Work best with consequences
 Work only in short term if no consequences
Consequences 2

 Getting what you don’t want

 Stronger than antecedents
 Criticism, injury, written warning
 “Consequences” has negative connotation  Stops unwanted behavior

 Positive consequences change behavior

Is not getting what you want
 Consequences strengthen or weaken behavior 

 Is no recognition, no
 Four categories of consequences acknowledgement
 Often decreases wanted or safe
1. Punishment behavior
 Can cause safe performers to slip
2. Extinction
3. Negative Reinforcement  Not getting what you don’t want

4. Positive Reinforcement  Avoiding criticism, unpleasant tasks,

or accidents
 Performing desired behavior to
avoid punishment
 Performing desired behavior only
when boss is watching
Positive Reinforcement 2

 Getting what you want

 Acknowledgement, recognition, better work assignments
 Maintains or increases desired behavior
 Gives discretionary effort (more than asked)
 Behavior occurs more frequently

 When – immediate or future

 Probability – certain or uncertain
Behavioral Theory 2

Often referred to as behavior-based safety (BBS)

 7 basic principles of BBS
1. Intervention
2. Identification of internal factors
3. Motivation to behave in the desired manner
4. Focus on the positive consequences of appropriate behavior
5. Application of the scientific method
6. Integration of information
7. Planned interventions
 3
Accident Studies
 Peterson (1978) in defining the principles of safety management says
that “an unsafe act, an unsafe condition, an accident are symptoms
of something wrong within the management system”
 All events represent a degree of failure in control and are potential
learning experiences. It therefore follows that all accidents should be
investigated to some extent.
Accident Investigation 3

It is important:
 To know the reasons for investigating accident/incidents
 To know the process for effective accident investigation
Accident Investigation 3

 Important part of any safety management system. Highlights the

reasons why accidents occur and how to prevent them.
 The primary purpose of accident investigations is to improve health
and safety performance by:
 Exploring the reasons for the event
 Identifying both the immediate and underlying causes
 Identifying remedies to improve the health and safety management system by
improving risk control, preventing a recurrence and reducing financial losses.
 3
What to Investigate?

 All accidents whether major or minor have cause(s)

 Serious accidents have the same root causes as minor accidents as
do incidents with a potential for serious loss. It is these root causes
that bring about the accident, the severity is often a matter of
chance.
 Accident studies have shown that there is a consistently greater
number of minor accidents than major accidents and in the same
way a greater number of incidents than accidents.
Many accident ratio studies have been undertaken and the 3
one shown below is based on Heinrich’s Domino theory

1
Major injury
Or illness

29
Minor injuries or illnesses

300
Non Injury Accidents/Illnesses
 Deal with immediate 3
risks.
 Whenaccidents/incidents occur
Select the level of
immediate action shall be:
investigation.  Make the situation safe and prevent further injury.
 Help, treat and if necessary rescue injured persons.

Investigate the event.  An

effective response can only be
made if it has been planned for in
Record and analyse the
advance.
results.

Review the process.

 Deal with immediate 3
risks.

Select the level of The greatest effort should be put into:

investigation.
 Those involving major injuries, ill-health or loss.
 Those which could cause greater harm or damage.
Investigate the event. These types of accidents/incidents demand more careful
investigation and management of time. This can usually
be achieved by:
Record and analyse the  Looking more closely at the underlying causes of significant
results. events.
 Assigning the responsibility for the investigation of more
significant events to more senior managers.
Review the process.
 Deal with immediate 3
risks.

Select the level of

investigation.

Investigate the event.

The purpose of investigations is to establish:

 The way things were and how they came to be.
Record and analyse the
results.  What happened – the sequence of events that led to the
outcome.
 Why things happened as they did analysing both the
Review the process. immediate and underlying causes.
 What needs to be done to avoid a repetition and how this can
be achieved.

O b s e rv a tio n
In fo rm a tio n fro m p h y s ic a l
s o u rc e s in c lu d in g :
 P re m is e s a n d p la c e o f
w o rk
 A c c e s s & e g re s s
 P la n t & s u b s ta n c e s in u s e
 L o c a tio n & re la tio n s h ip o f
p h ys ica l p a rtic le s
 A n y p o s t e v e n t c h e c ks ,
s a m p lin g o r
re c o n s tru c tio n
D o c u m e n ts
3
In fo rm a tio n fro m :
 W ritte n in s tru c tio n s ;
P ro c e d u re s, ris k
a s se s s m e n ts , p o lic ie s
 R e c o rd s o f e a rlie r
in s p e c tio n s , te s ts ,
e xa m in a tio n s a n d
s u rv e y s .
 C h e c k in g re lia b ility , a c c u ra c y
 Id e n tify in g c o n flic ts a n d re s o lvin g d iffe re n c e s
 Id e n tify in g g a p s in e v id e n c e
In te rv ie w s
In fo rm a tio n fro m :
 T h o s e in v o lve d a n d
th e ir lin e
m a n a g e m e n t;
 W itn e s s e s ;
 T h o s e o b s e rve d o r
in v o lv e d p rio r to th e
e v e n t e .g . in s p e c tio n
& m a in te n a n c e s ta ff.
 Interviews 3
 Interviewing the person(s) involved and witnesses to the accident is
of prime importance, ideally in familiar surroundings so as not to
make the person uncomfortable.
 The interview style is important with emphasis on prevention rather
than blame.
 The person(s) should give an account of what happened in their
terms rather than the investigators.
 Interviews should be separate to stop people from influencing each
other.
 Questions when asked should not be intimidating as the investigator
will be seen as aggressive and reflecting a blame culture.
 3
Observation

The accident site should be inspected as soon as possible after the

accident. Particular attention should/must be given to:

 Positions of people.
 Personnel protective equipment (PPE).
 Tools and equipment, plant or substances in use.
 Orderliness/Tidiness.
 Documents 3

 Written instructions, procedures and risk assessments which should

have been in operation and followed. The validity of these
documents may need to be checked by interview. The main points
to look for are:
 Are they adequate/satisfactory?
 Were they followed on this occasion?
 Were people trained/competent to follow it?
 Records of inspections, tests, examination and surveys undertaken
before the event. These provide information on how and why the
circumstances leading to the event arose.
Remedial actions should follow hierarchy of risk control: 3

1. Eliminate Risks by substituting the dangerous by the inherently less dangerous.

2. Combat risks at source by engineering controls and giving collective protective
measures priority.
3. Minimise risk by designing suitable systems of working.
4. Use PPE as a last resort......Video
 3
Deal with immediate
risks.  Complete as soon after the accident as possible.
 Record in a similar and systematic manner.
Select the level of  Provide a historical record of the accident.
investigation.  Analysis of the causes and recommended preventative
protective measures should be listed.
 Information on the accident and remedial actions should
Investigate the event.
be passed to all supervisors.
 Appropriate preventative measures may also have to be
implemented by such supervisors.
Record and analyse the
results.
 Investigation reports and accident statistics should be analysed
from time to time to identify common causes, features and trends
not be apparent from looking at events in isolation.

Review the process.

 Deal with immediate
3
risks.
Reviewing the accident/incident investigation
process should consider:
Select the level of
investigation.  The results of investigations and analysis.
 The operation of the investigation system (in terms of quality
and effectiveness).
Investigate the event. Line managers should follow through and action
the findings of investigations and analysis.
Follow up systems should be established where
Record and analyse the
results. necessary to keep progress under control.
The investigation system should be examined
from time to time to check that it consistently
Review the process.
delivers information in accordance with the
stated objectives and standards.
 Accident Investigation…. 3

1. Get help for the injured

2. Survey the scene
3. Secure the scene (initiate interim controls)
4. Collect evidence
 Interview accident witnesses
 Make documented observations on:
 Pre-accident conditions
 Accident sequence
 Post-accident conditions
 Witness remarks
 Contributing factors
5. Review all information (procedures, equipment manuals)
6. Analyze data
7. Determine causes (scientific methods – Root Cause Analysis)
8. Follow up (eliminate hazards)
BE SAFE!

A cow licks the wreck of a petrol tanker on the Rohtang Pass in

northern India