Chemical Process Safety

Accident Research: Introduction

Prof. Shishir Sinha
Department of Chemical Engineering

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What we will study in this module.
• Accident
• Some facts about Accident
• Accident Weed
• Accident Studies
• Accident Near miss
• Dangerous Occurrences
• Outcomes of Accident
• Accident causation theories

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What is an accident?

An unplanned, unwanted, but

controllable event which disrupts
the work process and causes injury,
death and/or damage to property,
equipment or materials to people.

All accidents have a cause and effect!

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 What is an accident?
Example: A 25 kg
An incident may disrupt the carton falls off the
work process, but does not top shelf of a 12’
result in injury or damage. high rack and lands
It should be looked as a “wake near a worker. This
up call”. event is unplanned,
It can be thought of, as the first unwanted, and has
of a series of events, which the potential for
could lead to a situation in injury.
which harm or damage does
occur.

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What is an accident?
Most Accident
Investigations
Conducted

Few Investigations
Conducted

Biggest
percentage
of injury-causing
potential!
Accidents Don’t just happen.
 Most workplace injuries and illness are not due to “accidents”.
 Let’s take our mythical 25 kg carton falling 12’, for the 2nd time, only
this time it hits a worker, causing injury. Predictable? Yes.
Preventable? Yes.
 Accident is defined as an unexpected or unintentional event, that it
was “just bad luck”. More often than not, it is a predictable or
foreseeable “eventuality”.

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THE ACCIDENT

Accidents have two things in common:

i. They all have outcomes from the accident.
ii. They all have contributory factors that cause
the accident.

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 Some facts about Accident?
 Employers should investigate an incident to determine the root cause
and use the information to stop process and behaviors that could just
as easily have resulted in an accident.
 It can be predictable, the logical outcome of hazards.
 Like if you touch the hot pan you will be burned.
 If the corner of the stainless steel counter is sharp it will cut
someone.
 So, we can say, accidents are predictable and
preventable events.

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 Some facts about Accident?
 Preventable and avoidable hazards do not have to exist.
 Example: Putting boxes in a pathway will cause someone to fall,
Wearing heatproof gloves when cleaning the fryer or grill will avoid a
burn.
 They are caused by things, people do, or fail to do.

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 Don’t investigate only accidents. Incidents should also be
reported and investigated.
“The Tip of the Iceberg”

Accidents
Accidents or injuries are the tip of
the iceberg of hazards.

Incidents
Investigate incidents since they are
potential “accidents in progress”.
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The “Accident Weed”[1]
Missing guard Horseplay

Poor housekeeping Ignored safety rules

Hazardous Defective tools Didn’t follow procedures
Conditions
Equipment failure
Did not report hazard
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 (Roots may not result in an accident but do contribute to it)
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Accident Studies[2]
 In all cases the ‘non injury’ incidents had the potential to become
events with more serious consequences.
 Such ratios clearly demonstrate that safety effort should be aimed
at all accidents, including unsafe practices at the bottom of the
pyramid, with a resulting improvement in upper tiers.
 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’s system.”

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Accident Studies

 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.
 This extent should be determined by the loss potential,
rather than just the immediate effect.

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THE ACCIDENT
BASIC TYPES OF ACCIDENTS
Minor Accidents:
 Such as paper cuts to fingers or dropping a box of materials.
More serious accidents that cause injury or damage to equipment or
property:
 Such as a forklift dropping a load or someone falling off a ladder.
Accidents that occur over an extended time frame:
 Such as hearing loss or an illness resulting from
exposure to chemicals.

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Damage or injury due to Accident includes:
• Sprain • Sickness due to exposure to a
• Laceration dangerous substance, fumes
• Broken bone or gases, fire or explosion
• Concussion • Sickness due to a chemical
spill or environmental
• Unconsciousness pollution
• Ill-health
• Damage to building
• Damage to property

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The Accident Near-Miss

 It is also know as a “Near Hit”.

 An accident that does not result in any injury or property damage
(but could have, as the potential for serious consequences existed).
 Remember, a Near-Miss is just as serious as an accident!

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Dangerous Occurrences

 Dangerous Occurrences are one of number of specific,

reportable adverse events with a high potential to cause
death or serious injury, but which happen relatively
infrequently.
 Dangerous Occurrences are reportable to the Health & Safety
Authority (HSA).

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Dangerous Occurrences
Dangerous occurrences usually include incidents involving:
• Lifting equipment
• Pressure systems
• Overhead electric lines
• Electrical incidents
• causing explosion or fire
• Explosions, biological agents
• Radiation generators and
radiography
• Breathing apparatus
• Diving operations
• Collapse of scaffolding
• Train collisions
• Pipelines or pipeline works
• Wells
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 All Accidents are ‘Incidents’.

However, the definition of an Incident is wider in that it includes

Dangerous Occurrences and Near Misses.

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OUTCOMES OF ACCIDENTS

The negative aspects of the accident outcomes

are named as follows:
o Injury & possible death
o Disease
o Damage to equipment & property
o Litigation costs, possible citations
o Lost productivity
o Morale

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 OUTCOMES OF ACCIDENTS
The positive aspects of the accident outcomes are named as follows:
o Accident investigation
o Prevent recurrence
o Change to safety programs
o Change to procedures
o Change to equipment design

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Incident Investigation
 When incidents are investigated, the emphasis
should be concentrated on finding the root cause
of the incident.
 It can prevent the event from happening again.
 The purpose is to find facts that can lead to
corrective actions, and not to find fault.
 Always look for deeper causes. Do not simply
record the steps of the event.

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Incident Investigation
Reasons to investigate a workplace incident include:
 Most importantly, to find out the cause of incidents and to
prevent similar incidents in the future.
 to fulfill any legal requirements.
 to determine the cost of an incident.
 to determine compliance with applicable regulations (e.g.,
occupational health and safety, criminal, etc.).
 to process workers' compensation claims.

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Accident Causes - Root Cause Analysis
 An investigator or team who believe that incidents are caused by
unsafe conditions, will likely try to uncover conditions as causes.
 One who believes they are caused by unsafe acts will attempt to
find the human errors that are causes. Therefore, it is necessary to
examine all underlying factors in a chain of events that ends in an
incident.

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Accident Causes - Root Cause Analysis
Many models of causation have been proposed, ranging from
Heinrich's domino theory to the sophisticated Management Oversight
and Risk Tree (MORT), each of which has some explanatory and
predictive value.
The domino theory Multiple Causation Theory
Human Factors Theory Pure chance theory
Accident/Incident Theory Based liability theory
Epidemiological Theory Accident proneness
Systems Theory theory

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Heinrich's Domino Theory[4]
 W.H. Heinrich, a safety engineer and pioneer in the field of
industrial accident safety, has developed this domino theory in
1931.
 According to this theory, 88% of all accidents are caused by unsafe
acts of people, 10% by unsafe actions and 2% by “acts of God”.
 He proposed a “five-factor accident sequence” in which each
factor would actuate the next step in the manner
of toppling dominoes lined up in a row.

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Heinrich's Domino Theory
The sequence of accident factors are as
follows:
 Ancestry and social environment,
 Worker fault,
 Unsafe act together with mechanical and
physical hazard,
 Accident,
 Damage or injury.

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Ferrell’s Human Factor Model[4]
 Ferrell defines accidents in terms of being the result of
an error by an individual.
 He explains this theory using the assumption that
accidents are caused by one person.
 Ferrell identifies three general causes of accidents:
overload, incompatibility and improper activities. Each
of these are actually broad categories that contain
several more specific causes.

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 Human Factors
Theory

Inappropriate Inappropriate
Response Activities
Overload - Detecting a hazard - Performing tasks
- Environmental but not correcting it. without the requisite
Factors - Removing training.
- Internal Factors safeguards from - Misjudging the
- Situational Factors machines and degree of risk
equipment. involved with a given
- Ignoring Safety. task.

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Ferrell’s Human Factor Model[4]
 Improper activities is perhaps the simplest of the concepts. It
encompasses two straightforward sources of accidents.
o It is possible that the responsible person simply didn’t know any
better.
o Alternatively, he or she may have known that an accident may
result from an action, but deliberately chose to take that risk.

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Ferrell’s Human Factor Model
 The incompatibility cause is slightly more complex than
improper activities. It encompasses:
o An incorrect response to a situation by an individual.
o Subtle environmental characteristics, such as a work station that
is incorrectly sized.

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Ferrell’s Human Factor Model
 Overload, is the most complex of Ferrell’s causes. It can further be
broken down into three subcategories.
o Emotional state of the individual accounts which include conditions like
unmotivated and agitated.
o Capacity refers to the individual’s physical and educational background.
Physical fitness, training and even genetics play a part. Situational factors,
such as exposure to drugs and pollutants, as well as job related stressors
and pressures, also affect one’s capacity.
o Load of the individual can also contribute. This include
the difficulty of the task, the negative or positive
effects of the environment (noise, distractions, etc.),
and even the danger level of the task.
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Dan Petersen’s Accident/Incident Model[2,4]
 Petersen’s model is largely an expansion upon Human Factor Model.
 Petersen conceptualized the environmental aspect of incompatibility
(work station design and displays/controls) as a different part of the
model, calling them ergonomic traps.
 He also separated a “decision to err” from the overload cause.
 Further, he also introduced a new element called system failures
(inability of the organization to correct errors, was added as a
possible mediator between errors and accidents).
 Overload, Ergonomic traps and Decision to err lead
to human error.

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Epidemiological Theory[4]
 The epidemiological theory of accident causation holds
that the models used for studying and determining the
relationships between environmental factors and
disease can be used to study causal relationships
between environmental factors and accidents.

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 Epidemiological Theory
Epidemiological
Theory

Situational
Predisposition Characteristics
Characteristics - Risk assessment by
- Susceptibility of people. individuals.
- Perceptions. - Peer Pressure.
- Environmental Factors - Priorities of Supervisor.
- Attitude.

Can cause or prevent accident

conditions.
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Systems Theory[4,5]
 A systems model theory approaches the relationship between
persons and their environments differently.
 Rather than the environment being full of hazards and a person
being error prone, the systems theory view a harmony between
person (host), machine (agency), and environment.
 Under normal circumstances, the chances of an accident are very
low.
 Once someone or something disrupts this harmony
by changing one of the components or the
relationships between the three, the probability of
an accident occurring increases substantially.
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Systems Theory
 Firenze (1978) suggests considering five calculated risks and
benefits:
o Job requirements
o The capabilities and limitations of the worker in relation to her or
her job
o The potential gain upon succeeding
o The potential consequences upon failure
o The potential loss of not attempting the task

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 Systems Theory
This model view sees a harmony between man, machine, and environment.
Under normal circumstances, the chances of an accident are very low. Once
someone or something disrupts this harmony by changing one of the
components or the relationships between the three, the probability of an
accident occurring increases substantially.

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Multiple Causation Theory
 It is an outgrowth of the domino theory.
 It postulates, that for a single accident there may be many contributory
factors, causes and sub-causes, and that certain combinations of these
give rise to accidents.
 The major contribution of this multiple causation theory is that, very
rarely it can happen that, there will be an accident because of a single
cause or act.

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Multiple Causation Theory
According to this theory, the contributory factors
can be grouped into the following two categories:
 Behavioral: This category includes factors
pertaining to the worker, such as improper
attitude, lack of knowledge, lack of skills and
inadequate physical and mental condition.
 Environmental: This category includes improper
guarding of other hazardous work elements and
degradation of equipment through use and
unsafe procedures.

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The pure chance theory
 According to this theory, every one of any given set of workers has an
equal chance of being involved in an accident.
 It further implies that there is no single discernible pattern of events
that leads to an accident.
 In this theory, all accidents are treated as corresponding to Heinrich’s
acts of God, and it is held that there exist no interventions to prevent
them.

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Biased liability theory
 It is based on the fact that once a worker is involved in an accident,
the chances of the same worker becoming involved in future
accidents are either increased or decreased as compared to the rest
of workers.
 This theory contributes very little, if anything at all, towards
developing preventive actions for avoiding accidents.

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Accident Proneness Theory
• It maintains that within a given set of workers, there exists a
subset of workers who are more liable to be involved in accidents.
• Researchers have not been able to prove this theory conclusively
because most of the research work has been poorly conducted
and most of the findings are contradictory and inconclusive.
• This theory is not generally accepted.
• It is felt that if indeed this theory is supported by
any empirical evidence at all, it probably accounts
for only a very low proportion of accidents without
any statistical significance.

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Reason’s Swiss Cheese Model[7]
 James Reason’s Swiss Cheese Model was originally proposed in
1990.
 Each layer of defense is represented by a slice of Swiss cheese, and
the possible problems or failures in that defense are represented by
the holes in the cheese.
 There are two types of failures that can occur: active and latent.
 Active failures are unsafe acts that directly
contribute to an accident while Latent failure are
conditions that exist that may lay dormant for a
period of time until they lead to an accident.

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Reason’s Swiss Cheese Model
 An example of a latent failure could be the lack of a policy
describing how a given work task should be completed safely.
 For an accident to happen, the holes have to line up – no layer of
defense caught the problem. If the holes do not line up, then the
problem was caught, and no accident occurs.

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Energy Transfer Theory[7]
 There is a source, a path and a receiver for every change of energy.
 This change of energy resulted in a damage of equipment or worker
injury.
 This theory is useful for determining injury causation and evaluating
energy hazards and control methodology.
 Strategies can be developed which are either preventive, limiting or
ameliorating with respect to the energy transfer.

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Energy Transfer Theory
Control of energy transfer at the source can be achieved by the
following means:
 elimination of the source,
 changes made to the design or specification of elements of the work
station,
 preventive maintenance.

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Energy Transfer Theory
The path of energy transfer can be modified by:
 enclosure of the path,
 installation of barriers,
 installation of absorbers,
 positioning of isolators.
The receiver of energy transfer can be assisted by adopting the
following measures:
 limitation of exposure,
 use of personal protective equipment.

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References
1. http://www.oshainfo.gatech.edu/21d-program.html
2. Peterson D. (1978) Techniques of Safety Management, 2nd Edition, McGraw Hill, New
York.
3. Crowl D.A. and Louvar J.F., Chemical Process Safety: Fundamentals With Applications,
Prentice Hall, third edition.
4. Whitney DeCamp, Kevin Herskovitz, The Theories of Accident Causation, Security
Supervision and Management, December 2015. DOI: 10.1016/B978-0-12-800113-
4.00005-5
5. https://www.slideshare.net/yorkypab/theories-of-accident-causation
6. http://wps.prenhall.com/chet_goetsch_occupation_7/139/35769/9157107.cw/-
/9157132/index.html
7. http://www.iloencyclopaedia.org/part-viii-12633/accident-prevention/92-56-
accident-prevention/theory-of-accident-causes

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References
8. Firenze, R. J. (1978). The Process of Hazard Control. New York: Kendall/Hunt.
9. Haddow, G. D. and Bullock, J. A. (2006). Introduction to Emergency Management
(2nd ed.). Oxford: Butterworth-Heinemann.
10. Heinrich, H. W. (1950). Industrial Accident Prevention (3rd ed.). New York: McGraw
Hill.
11. Heinrich, H. W., Petersen, D., and Roos, N. (1980). Industrial Accident Prevention.
New York: McGraw-Hill.
12. Herzberg, F., Mausner, B., and Snyderman, B. B. (1959). The Motivation to Work. New
York: John Wiley.

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Thank You

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