Accident Causation Why Do We Have Accidents Updated

Accident Causation Why Do We Have Accidents? Updated 1 July 2014

Causation History n n U. S. ARMY COMBAT READINESS CE Early man – Accidents were the result of Bad Spirits Civilized man - Injured person was at fault due to stupidity

U. S. ARMY COMBAT READINESS CE

Causation History n U. S. ARMY COMBAT READINESS CE Industrial revolution – carelessness caused accidents. • Natural side effect of production • Cost of doing business • Human nature – people will always be careless

Causation History n The court system • • • n U. S. ARMY COMBAT READINESS CE Upheld the view of individual responsibility Injured worker had to sue Employer had to be found completely to blame Public opinion • Rose against rose against the "worker alone-is-to-blame" theory. • Courts became more responsive to workers' claims. • By 1908 State legislatures implemented an employer's liability law.

Causation History n U. S. ARMY COMBAT READINESS CE Employers take notice • Financial responsibility for an injured worker • More cost effective to prevent accidents. • Only theory remained personal carelessness • Safety program success was hit and miss

Industrial Revolution U. S. ARMY COMBAT READINESS CE Natural Side Effect of Production “Acts of God” ACCIDENTS Number Is Up Approach People Errors Carelessness Employers Rationale for Accidents

Heinrich’s Theory n U. S. ARMY COMBAT READINESS CE Scientific Approach Heinrich’s model to accident causation has been the basic approach in accident prevention and has been used mostly by safety societies and professional people since its publication in 1932. This was the first scientific approach.

Heinrich’s Accident Causation Model Social Environment & Ancestry Fault of the Person Unsafe Act Or Unsafe Condition Mistakes of People U. S. ARMY COMBAT READINESS CE Accident Injury

Accident Causation U. S. ARMY COMBAT READINESS CE 1932 - First Scientific Approach To Accident Prevention – H. W. Heinrich “Industrial Accident Prevention” Social Environment And Ancestry Fault of the Person (Carelessness) Unsafe Act Or Condition Mistakes of People Accident Injury

Three “E’s” of Accident Prevention n Engineering n Education n Enforcement U. S. ARMY COMBAT READINESS CE

Beyond Engineering n Instruction n Persuasion n Discipline U. S. ARMY COMBAT READINESS CE

Modern Causation Model n n U. S. ARMY COMBAT READINESS CE Parallels Heinrich’s theory “Injury” becomes “Result” • Varies from no damage to very severe n “Accident” becomes “Mishap” • Injury not required n “Unsafe Act or Unsafe Condition” becomes “Operating Error” • Act and condition captured as error

Modern Causation Model U. S. ARMY COMBAT READINESS CE No damage or injury OPERATING ERROR RESULTS MISHAP Major damage Or fatalities

Modern Causation Model U. S. ARMY COMBAT READINESS CE Disrupted Operation No damage or injury OPERATING ERROR RESULTS MISHAP RESULTS Major damage Or fatalities

Modern Causation Model Event U. S. ARMY COMBAT READINESS CE Disrupted Operation No damage or injury OPERATING ERROR RESULTS MISHAP RESULTS Major damage Or fatalities

Modern Causation Model Failure to properly operate or maintain facilities or equipment Event U. S. ARMY COMBAT READINESS CE Injury or damage No damage or injury OPERATING ERROR RESULTS MISHAP RESULTS Major damage Or fatalities

Modern Causation Model Single Most Important Addition to New Model System Defect U. S. ARMY COMBAT READINESS CE SYSTEM DEFECT No damage or injury OPERATING ERROR MISHAP RESULTS Major damage Or fatalities

System Defects n U. S. ARMY COMBAT READINESS CE Weaknesses in the way the system is designed or operated • Improper assignment of responsibilities • Improper climate of motivation • Inadequate training and education • Inadequate or improper equipment or supplies • Poor personnel selection for job • Inadequate funding

Modern Causation Model U. S. ARMY COMBAT READINESS CE COMMAND/ MANAGEMENT ERROR SYSTEM DEFECT No damage or injury OPERATING ERROR MISHAP RESULTS Major damage Or fatalities

Management Error n Managers • Design systems • Create procedures • Enforce discipline • Provide training Why does the manager fail to identify system defects or take action? U. S. ARMY COMBAT READINESS CE

Modern Causation Model SAFETY PROGRAM DEFECT U. S. ARMY COMBAT READINESS CE COMMAND/ MANAGEMENT ERROR SYSTEM DEFECT No damage or injury OPERATING ERROR MISHAP RESULTS Major damage Or fatalities

Safety Program Defect n Ineffective information collection n Weak causation analysis n Poor countermeasures n Inadequate controls n Inadequate programs U. S. ARMY COMBAT READINESS CE

Modern Causation Model SAFETY MANAGEMENT ERROR SAFETY PROGRAM DEFECT U. S. ARMY COMBAT READINESS CE COMMAND/ MANAGEMENT ERROR SYSTEM DEFECT No damage or injury OPERATING ERROR MISHAP RESULTS Major damage Or fatalities

Safety Management Error n Knowledge n Motivation n Integration n Relevance U. S. ARMY COMBAT READINESS CE

Accidents & Near Misses Heinrich’s Initial Research U. S. ARMY COMBAT READINESS CE Recent Studies 1 Serious 1 29 Minor 59 300 Near Miss 600

Seven Avenues U. S. ARMY COMBAT READINESS CE 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

Modern Causation Model 1 2 SAFETY MANAGEMENT ERROR SAFETY PROGRAM DEFECT 5 OPERATING ERROR U. S. ARMY COMBAT READINESS CE 3 4 COMMAND/ MANAGEMENT ERROR 6 MISHAP SYSTEM DEFECT No damage or injury RESULTS Major damage Or fatalities 7

Seven Avenues U. S. ARMY COMBAT READINESS CE Potential Countermeasures 1 SAFETY MANAGEMENT ERROR TRAINING EDUCATION MOTIVATION TASK DESIGN 2 3 4 5 6 7

Seven Avenues U. S. ARMY COMBAT READINESS CE Potential Countermeasures 2 1 SAFETY PROGRAM DEFECT REVISE INFORMATION COLLECTION ANALYSIS IMPLEMENTATION 3 4 5 6 7

Seven Avenues U. S. ARMY COMBAT READINESS CE Potential Countermeasures 3 1 2 COMMAND/ MANAGEMENT ERROR TRAINING EDUCATION MOTIVATION TASK DESIGN DISCIPLINE SUPPORT 4 5 6 7

Seven Avenues U. S. ARMY COMBAT READINESS CE Potential Countermeasures 4 1 2 3 SYSTEM DEFECT 5 6 7 DESIGN REVISION VIA-- SOP - REGULATIONS - POLICY LETTERS - STATEMENTS

Seven Avenues U. S. ARMY COMBAT READINESS CE Potential Countermeasures 5 1 2 3 4 OPERATING ERROR ENGINEERING SAFETY DEVICES WARNING DEVICES TRAINING MOTIVATION 6 7

Seven Avenues U. S. ARMY COMBAT READINESS CE Potential Countermeasures 6 1 2 3 4 5 MISHAP 7 PROTECTIVE EQUIPMENT BARRIERS SEPARATION

Seven Avenues U. S. ARMY COMBAT READINESS CE Potential Countermeasures 7 1 2 3 4 5 6 RESULT CONTAINMENT FIREFIGHTING RESCUE EVACUATION FIRST AID Systems Model

U. S. ARMY COMBAT READINESS CE Conclusion The Army approach to accident causation allows us to: 1. 2. 3. Look beyond the individual ID the systemic defect Use the information to develop controls & prevent accidents

Army Systems Model SAFETY MANAGEMENT ERROR SAFETY PROGRAM DEFECT COMMAND ERROR Army Systems Model • • • Task Person Training Environment Materiel SYSTEM DEFECT U. S. ARMY COMBAT READINESS CE RESULT MISHAP OPERATING ERROR

Army Systems Model U. S. ARMY COMBAT READINESS CE A system is simply a group of interrelated parts which, when working together as they were designed to do, accomplish a goal. Using this analogy, an installation or organization can be viewed as a system.

Army Systems Model U. S. ARMY COMBAT READINESS CE The elements of the Army Systems Model are: § Task § Person § Training § Environment § Materiel

Army Systems Model TASK • Communication Control • Arrangement • Demands on soldiers • Time aspects U. S. ARMY COMBAT READINESS CE

Army Systems Model PERSON Selection Motivation • Mentally • Positive • Physically • Negative • Emotionally • Retention • Qualified U. S. ARMY COMBAT READINESS CE

Army Systems Model U. S. ARMY COMBAT READINESS CE TRAINING Types Targets Considerations • Initial • Operator • Quality/Quantity • Update • Supervisor • Remedial • Management

Army Systems Model ENVIRONMENT • Noise • Weather • Facilities • Lighting • Ventilation U. S. ARMY COMBAT READINESS CE

Army Systems Model MATERIEL • Supplies • Equipment • Machine Design • Maintenance U. S. ARMY COMBAT READINESS CE

U. S. ARMY COMBAT READINESS CE DA PAM 385 -40 3 W’s Approach to Information Collection, Analysis and Recommendations Why Did it Happened ? What Happened ? (cause Factors) • Human Mistakes/Errors • Materiel Failure • Environmental Factors (System Inadequacies/Root Cause) • Leader What to do About it ? (Recommendations) • Training • STDS / Procedures • Support • Individual • Fixes • Remedial Measures • Countermeasures

U. S. ARMY COMBAT READINESS CE RECENT STUDIES 1 59 600 SERIOUS MINOR NEAR MISS

U. S. ARMY COMBAT READINESS CE How to analyze the Near Miss 1. Identify the systemic defect

U. S. ARMY COMBAT READINESS CE Army System Model Task Training Environment Material SYSTEM DEFECT Person

U. S. ARMY COMBAT READINESS CE How to analyze the Near Miss 1. 2. Identify the systemic defect Identify cause factors:

U. S. ARMY COMBAT READINESS CE Cause Factors Why Did it Happened ? What Happened ? (cause Factors) • Human Mistakes/Errors • Materiel Failure • Environmental Factors (System Inadequacies/Root Cause) • Leader What to do About it ? (Recommendations) • Training • STDS / Procedures • Support • Individual • Fixes • Remedial Measures • Countermeasures

U. S. ARMY COMBAT READINESS CE What Happened ? (Cause Factors) • Human Mistakes/Errors • Materiel Failure • Environmental Factors

U. S. ARMY COMBAT READINESS CE How to analyze the Near Miss 1. 2. Identify the systemic defect Identify cause factors: • n Human, Materiel, Environmental If human – • • Identify the system inadequacies, the root cause Leader, Training, Standards, Support, Individual

U. S. ARMY COMBAT READINESS CE System Inadequacies Why Did it Happened ? What Happened ? (cause Factors) • Human Mistakes/Errors • Materiel Failure • Environmental Factors (System Inadequacies/Root Cause) • Leader What to do About it ? (Recommendations) • Training • STDS / Procedures • Support • Individual • Fixes • Remedial Measures • Countermeasures

U. S. ARMY COMBAT READINESS CE Why Did it Happened ? (System Inadequacies/Root Cause) 1. Leader 2. Training 3. STDS / Procedures 4. Support 5. Individual

U. S. ARMY COMBAT READINESS CE Near Miss - Summary 1. 2. Identify the systemic defect Identify cause factors: • n Human, Materiel, Environmental If human – • • Identify the system inadequacies and root cause Leader, Training, Standards, Support, Individual

U. S. ARMY COMBAT READINESS CE