ACCIDENT CAUSATION

& SAFETY CULTURE

DEVLOPMENT

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 ACCIDENT : AN UNPLANNED, UNDESIRED EVENT, NOT
NECESSARILY RESULTING IN INJURY, BUT DAMAGING
THE PROPERTY AND / OR INTERRUPTING THE
ACTIVITY IN PROCESS

NEAR MISS : THE ACCIDENT WHICH HAS NOT RESULTED IN INJURY

OR PROPERTY DAMAGE BUT HAS POTENTIAL TO
CAUSE INJURY / PROPERTY DAMAGE.

FIRST AID CASE : THE ACCIDENT RESULTED IN MINOR INJURY,

WHERE IN THE INJURED PERSON IS SENT BACK TO
WORK.

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MINOR ACCIDENT : Any occupational injury that requires treatment at plant
dispensary which results in the employ loosing man hours
less than 48 hrs. Regardless of man-hours lost 1st degree
burn, sutures, embedded foreign bodies, loss of
consciousness would be Minor Accident.

MAJOR ACCIDENT : An occupational injury in which the injured person is

treated in plant dispensary and if the injured person
is not resumed to his duties within 48 hrs or if the
injured person is sent to the hospital, outside the plant,
for further treatment, or the case of fracture, 2nd & 3rd
degree burn, amputation of body part, permanent
disability or death.
(It is a reportable lost time accident which is to be reported to factory
inspector)

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INCIDENT = ACCIDENT + NEAR MISS

TODAY + SAFETY = TOMMROW

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5
“The Tip of the Iceberg”
Accidents
Accidents or injuries are the tip of
the iceberg of hazards
Investigate incidents since they are
potential “accidents in progress”

Incidents

Don’t just investigate accidents. Incidents should also be reported and investigated. They were in a
sense, “aborted accidents”.
What is reasonably the worst outcome, equipment damage, or injury to the worker? What might the
severity of the worst outcome have been? If it would have resulted in significant property loss or a
serious injury, then the incident should be investigated with the same thoroughness as an actual
accident investigation.
The 50 pound carton falls off the top shelf of a 12’ high rack and lands near a worker. The outcome of
an investigation might include correction of sloppy storage at several locations in the warehouse,
unstable/heavy items will be stored at floor level if possible, refresher training of stockers
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on proper
methods is done, supervisor begins doing daily checks.
 Near-Miss Relationship
 Henrich a insurance agent after studying 5000 lost time accidents concluded that
for every accident resulting an injury there are many other similar accidents that
cause no injury , It was estimated by him that in a unit group of 330 accident of
same kind involving same person and similar circumstances 300 resulted in no
injury , 29 in minor injury and 1 in lost time injury.
 Initial studies show for each disabling injury, there were 29 minor injuries and 300
close calls/no injury/Near Miss.
 Recent studies indicate for each serious result there are 59 minor and 600 near-
misses.

HENRICH PYRAMID FOR ACCIDENT CAUSATION

INITIAL STUDIES RECENT STUDIES

1 SERIOUS 1 SERIOUS

29 MINOR 59 MINOR

300 NEAR MISS 600 NEAR MISS

UNSAFE ACTIONS & UNSAFE ACTIONS &
UNSAFE CONDITIONS UNSAFE CONDITIONS
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 Industrial Revolution
Factory managers reasoned that
workers were hurt because —
Number is Up
Carelessness People Error

ACCIDENT
Cost of doing
Act of God
Business
PEOPLE PROBLEM
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Domino Theory
1932 First Scientific Approach to
Accident/Prevention - H.W. Heinrich.
“Industrial Accident Prevention”

Social Fault of the Unsafe Act

Environment Person or Accident Injury
and Ancestry (Carelessness) Condition

MISTAKES OF PEOPLE
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Heinrich’s Theorems (MODIFIED BY FRANK BIRD Jr)

INJURY - caused by accidents.

ACCIDENTS - caused by an unsafe act –
injured person or an unsafe condition –
work place.
UNSAFE ACTS/CONDITIONS - caused by
careless persons or poorly designed or
improperly maintained equipment.
FAULT OF PERSONS - created by social
environment or acquired by ancestry.
SOCIAL ENVIRONMENT/ANCESTRY - where
and how a person was raised and educated.
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SINGLE CAUSE DOMINO THEORY

If one of the dominoes is removed

then the chain of events will be
halted, and the accident will not
happen
Element 3 (unsafe act and/or
mechanical or physical hazard) is
probably the easiest factor to remove

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Single Cause Domino Theory

Bird & Loftus extended Heinrich’s theory to encompass the

influence of management in the cause & effect of accidents
They suggested a modified sequence as follows:
Lack of management control, permitting
Basic causes (personal & job factors), leading to
Immediate causes (substandard practices or conditions), which are the
direct cause of
The accident, which results in
Loss (negligible, minor, serious or catastrophic
This modified sequence can be applied to every accident and is
of basic importance to loss control management

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MULTIPLE CAUSATION

May be more than one cause, not only in

sequence, but occurring at the same time
In accident investigation all causes must be
identified
Usually simple accidents have a single cause
Major disasters normally have multiple causes

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MULTIPLE CAUSATION

Cause a

Cause b Unsafe Act

Cause c

Injury or
Accident
Damage

Cause d

Unsafe
Cause e
Condition

Cause f

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UNSAFE ACTS
Categories:
Operating without clearance
Operating at unsafe speed
Rendering safety devices inoperative
Using unsafe equipment, or using it unsafely
Unsafe methods e.g. loading, carrying, mixing
Adopting unsafe position or posture
Working on moving or dangerous equipment
Horseplay e.g. distracting, teasing, startling
Failure to wear PPE
Lack of concentration; fatigue or ill health
Human Factors

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UNSAFE ACTS

Unsafe acts can be active or passive:

Active Unsafe Acts:
Worker deliberately removes machine guard
Passive Unsafe Acts:
More difficult to deal with
By pursuing an active safety policy, it is possible to
achieve a reduction in bad habit s and hence accidents

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UNSAFE CONDITIONS
Categories:
Inadequate guarding
Unguarded machinery
Defective, rough, sharp, slippery, decayed, cracked surfaces
Unsafely designed equipment
Poor housekeeping, congestion
Inadequate lighting, glare, reflections
Inadequate ventilation, contaminated air
Unsafe clothing or PPE
Unsafe processes
Hot, humid or noisy environment

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UNSAFE ACTS/CONDITIONS
The picture shows how unsafe acts & conditions may interact to produce an
accident. Accident potential is increased when unsafe acts & conditions
occur simultaneously. Of course, this is not to say that an act or condition
alone could not result in an accident.

Potential
Accident
Unsafe Unsafe
Conditions
Acts
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Corrective Action Sequence
(The Five “E”s)

 ENGINEERING
 EDUCATION
 ENFORCEMENT
 ENTHUSIASM
 EVALUATION

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 Engineering :- Starts in project stage in this details like
materials , process , equipments
,technology is finalized ex is HAZOP

 Education:- In this knowledge of hazard , risk ,safe

operating procedures, PPE can be taught to
employees

 Enforcement:- If safety efforts fail after education and

training it becomes necessary to enforce
rules and procedures for there welfare.

 Enthusiasm:- Motivate employees to act and do job safely

by safety award , contest , competition

 Evaluation:- Continues evaluation of safety programmes,

procedures, and performance by top
management through review meetings
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Incident Ratio

FRANK BIRD RATIO

1 Serious or
Major Injury
10 Minor
Injuries
30 Damage
Incidents
600 Near Miss

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 Loss Causation Model (Bird)
Management Basic Immediate Incident Loss
(Lack of Causes Causes
Personal Event Unintended
Control) Substandard Harm or
System Factors Acts/Practices Damage
Standards Substandard
Job/System
Compliance Conditions
Factors

Lack of control :- The work control means lack of planning , organizing ,leading and controlling)

Basic causes – 1) Personnel factor : Lack of knowledge , improper motivation and mental problem
2) Job factor : Inadequate design , inadequate work standards

Immediate Cause :- This are referred as unsafe act and unsafe conditions.

Accidents (Incidence) :- When ever unsafe act and conditions exist ,the result of occurrence of
accidents that may or may not result in loss is likely.

Injury / Damage :- Means Personal harm , disease or human system failure or health effect , Damage
means Property damage , equipment damage
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Modern
Causation Model
RESULT:

-No damage
OPERATING MISHAP or injury
ERROR (POSSIBLE)

-Many fatalities
-Major damage

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Modern Causation
How accidents are caused &
how to correct those causes.
Parallels Heinrich's to a point.
 Injury is called RESULT, indicating it could
involve damage as well as personal injury
and the result can range from no damage
to the very severe.
 The word MISHAP is used rather than Accident
to avoid the popular misunderstanding that an
accident necessarily involves injury or damage.
 Finally, the term OPERATING ERROR is used
instead of Unsafe Act & Unsafe condition.
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Examples

Operating Errors:
 Being in an unsafe position
 Stacking supplies in unstable
stacks
 Poor housekeeping
 Removing a guard

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Systems Defect

 Revolutionized accident
prevention

 A weakness in the
design or operation of
a system or program

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Examples

Systems defects include:

 Improper assignment of responsibility
 Improper climate of motivation
 Inadequate training and education
 Inadequate equipment and supplies
 Improper procedures for the selection &
assignment of personnel
 Improper allocation of funds

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Modern Causation Model
RESULT:

-No damage
or injury
SYSTEM OPERATING MISHAP
DEFECTS ERRORS (POSSIBLE)
-Many
fatalities
Operating Errors occur because -Major damage
people make mistakes,
but more importantly,
they occur because of
SYSTEM DEFECTS
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Modern Causation Model
Managers design the Systems

COMMAND
ERROR RESULT:

-No damage
or injury
SYSTEM OPERATING MISHAP
DEFECTS ERRORS (POSSIBLE)
-Many
fatalities
-Major damage
System defects occur because of
MANAGEMENT / COMMAND ERROR
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Safety Program Defect
A defect in some aspect of the
safety program that allows an
avoidable error to exist.
 Ineffective Information Collection
 Weak Causation Analysis
 Poor Countermeasures
 Inadequate Implementation Procedures
 Inadequate Control
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Safety Management Error
A weakness in the knowledge or
motivation of the safety manager
that permits a preventable defect
in the safety program to exist.

SAFETY
MANAGEMENT
ERROR

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Modern Causation Model
SAFETY SAFETY
COMMAND
MANAGEMENT PROGRAM
ERROR
ERROR DEFECT

SYSTEM OPERATING
MISHAP
DEFECT ERROR

RESULTS

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Seven Avenues
There are seven avenues through which
we can initiate countermeasures. None
of these areas overlap. They are:
 Safety management error
 Safety program defect
 Management / Command error
 System defect
 Operating error
 Mishap
 Result
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Seven Avenues
Potential countermeasures for each modern
causation approach include:

1
SAFETY
MANAGEMENT
ERROR
2 3 4 5 6 7
TRAINING
EDUCATION
MOTIVATION
TASK DESIGN

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Seven Avenues
Potential countermeasures for each modern
causation approach include:

2
SAFETY
1 PROGRAM
DEFECT
3 4 5 6 7
REVISE INFORMATION
COLLECTION
ANALYSIS
IMPLEMENTATION

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Seven Avenues
Potential countermeasures for each modern
causation approach include:

3
COMMAND
1 2 ERROR 4 5 6 7
TRAINING
EDUCATION
MOTIVATION
TASK DESIGN

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Seven Avenues
Potential countermeasures for each modern
causation approach include:
4
SYSTEM
1 2 3 DEFECT 5 6 7
DESIGN REVISION VIA--
- SOP
- REGULATIONS
- POLICY LETTERS
- STATEMENTS
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Seven Avenues
Potential countermeasures for each modern
causation approach include:

5
OPERATING
1 2 3 4 ERROR 6 7
ENGINEERING
TRAINING
MOTIVATION

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Seven Avenues
Potential countermeasures for each modern
causation approach include:

6
1 2 3 4 5 MISHAP 7
PROTECTIVE EQUIPMENT
BARRIERS
SEPARATION

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Seven Avenues
Potential countermeasures for each modern
causation approach include:

7
1 2 3 4 5 6 RESULT

CONTAINMENT
FIREFIGHTING
RESCUE
EVACUATION
FIRST AID
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AN INTRODUCTION TO
Behavior Based Safety (BBS)

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 Traditional Safety Model

Safety Training
Slogans
Policies

R R
e eg
p ul
ri at
m Fewer Accidents io
a ns
n
ds

Committees & Councils

Contests &
Safety Meetings
Awards
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 Traditional Safety Management
Safety Management
System Features

PPE Emergency Response Policies

Safety Rules injuriesIncident Investigation
Procedures Purpose: To reduce/eliminate
in the workplace.
Safety Meetings Audits/Inspections Industrial Hygiene
Limited effectiveness, why? Hazard Recognition
Training SafetyonPermits
Strong reliance Antecedents
Fire Protection Engineering Ergonomics
Safety Surveys Safety Incentives
SHE Standards
Job Safety Analysis JSO
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Please think . . .
How many of the above elements can
be directly traced to injury elimination
just at the moment the injury is about
to occur ?

Question: Are injuries totally eliminated?

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Injury Statistics . . .
14 people die at work in US everyday

11,000 people suffer from disabling injury

everyday

Question: Are injuries totally eliminated?

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Injury Statistics . . . Year 2004 in US*

•5200 workplace fatalities

•3.8 fatalities per 100,000 workers
•3.9 million people suffer disabling injuries
•6.1 injuries or illnesses per 100 workers

Question: Are injuries totally eliminated?

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Injury Statistics . . . In INDIA
•124 people die at workplace everyday
•46575 people are injured
•32% contribution to global fatality at work
•37% of global burden of occupational injury

Question: Are injuries totally eliminated?

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To Conclude . . .
•Good Safety Management systems exist
•Still workplace is injury prone & not safe
•Injury although declined, still persists

WHAT IS MISSING?
WHERE IS THE CATCH?

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Scientifically proven that . . .

In 1951, Dr. Heinrich claimed that more than 90%

of injuries were caused by UNSAFE ACTS

DuPont proved by research that:

Injury Causes Percent

Injuries due to Unsafe Acts / Behavior 76
Injuries due to combination of Unsafe Behavior
20
& Conditions
Injuries due Unsafe Conditions 4

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DOE, US Govt. found out that . . .

Percent by Cause (1999-2001)

100

80

60

40

20

0
Eq Pr o Per De Tra Ma O th
u ipm ce d son sig inin nag ers
ent ure nel n g em
Er r ent
or

Personnel errors (Unsafe Acts) was present in 77%

of incidents 50
 DuPont Research found that . . .

Avoid
1
Fatal

30 LTAs

300 Non LTAs

3,000 Near Miss / First

Aid

30,000 Hazards
Eliminate (Unsafe Acts & Conditions)

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To Conclude . . .

Eliminate Unsafe Acts / Conditions = Avoid Injuries & Accidents

Safety
Activities

Fewer Unsafe
Acts
Fewer
Accidents
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UNSAFE ACTS & OBJECTIVES OF BBS
1. Unsafe Acts is a behavioral process

2. Also defined as “at risk” behavior

Objective of BBS is to minimize “at

risk” behavior at workplace

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Principles of BBS

Behavior is the cause of accidents

Consequence motivate behavior
What gets measured, gets done
Feedback is essential to improvement
Quality is built early in the process
Conversations change organizations

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 Behavioral Safety Management
Safety Management
System Features
Policies
PPE Emergency
Purpose: To Response
reduce/eliminate injuries
in the workplace.
Procedures Safety Rules Incident
Safety Improvement: Adding Consequences Investigation
Audits/Inspections
Meetings Industrial Hygiene
Training
But,
Safety Permits Hazard
Recognition
Still limited Engineering
effectiveness, why?
Fire Protection Not integrated with other elements Ergonomics
Safety Surveys OSHA Standards Safety Incentives
Behavioral Safety JSO
Job Safety Analysis 55
Behavioral Safety Management
To be effective:
Integrate the fundamental elements of
BBS into the Safety Management
System elements
How?
Identify (pinpoint) critical behaviors
Define behaviors precisely to measure them
reliably
Implement mechanisms to determine current
status
Provide feedback
Reinforce progress 56
 What is Behavior?
Behavior is anything that a person says,
does, thinks or feels

Eg: Working at heights with safety belts

Behavior should be observable, specific

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What is Antecedent ?
Anything that occurs before or during the
behavior can be an antecedent for that
behavior

B: Working at heights with safety belts

A: Painful Memory of past accident

It is Antecedents that cause a certain types

of behavior to happen

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What is Consequence ?

Anything that occurs after a behavior

B: Working at heights with safety belts

A: Painful Memory of past accident
C: No more accidents

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The ABC of BBS Program

A: Antecedents – cause of certain behavior

B: Behavior – what you see a person do

C: Consequence – outcome of a behavior

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What is BBS Program?

Understand & Influence Antecedents

Make people behave safely, work safely

Minimize / eliminate workplace injuries

This is Zero Injury Culture too . . .

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BBS vs. Zero Injury

Zero Injury is the GOAL

BBS is the path to reach the GOAL

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How to Implement BBS ?
7 Steps Process

1. Identify Unsafe Acts in all your

operations. Make a list of safe acts for
these unsafe acts.
2. Audit Unsafe Acts & Conditions. Report

3. Measure no. of safe / unsafe acts.

Know your scores
4. Set Improvement Goals. Identify
actions to achieve the goals. Implement
Actions 63
How to Implement BBS ?
7 Steps Process

5. Monitor actions implementation &

trends of Unsafe Acts & conditions
6. Continually improve performance

7. Recognize performers & celebrate

achievement

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 Q: Why focus on behavior?

Serious Injuries
Reactive
Non Serious Injuries

Near Misses

At-Risk Behaviors
Proactive

Systems’ Weaknesses

A: It’s the best way of measuring how well your system is working!
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Recall . . .

Safety
Activities

Fewer Unsafe Acts

Fewer
Accidents

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What do we do now?

Safety
Activities BBS Program + Traditional
Model

Fewer Unsafe Acts

Fewer
Accidents
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Primary Team Roles
Management
Lead by example
Support the process
Remove roadblocks
Monitor success
Provide resources

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Basic Elements of BBS
Identify/define targeted safe
behaviors.
Observe behaviors.
Measure process/activities.
Deliver feedback.
Deliver positive consequences.
Analyze variance/take action.
Improve process continuously.
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The Behavioral Process

CRITICAL SAFE
& PROCESS
RESULTS
SUPPORT
BEHAVIORS

PERFORMANCE
IMPROVEMENT PERFORMANCE

VERBAL &
GRAPHIC ON
PERFORMANCE

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If BBS has to Succeed then . . .
Top Management Commitment is essential
Ownership & involvement from all employees
Steering Committee to monitor in plants
Training to all on BBS & safety practices
Effective Feedback – Most important
Performance monitoring & Continual
improvement

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Safe Behavior

Is safe behavior an occupational necessity?

Is safety only at work place?

Don’t I want my son to drive safely & reach

home every day?

Can safe behavior be a philosophy of life?

Safe Behavior = Safety Assurance

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Thank you

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