OSH 367-Human Factors- W3_A3

Ferrel Human Factors Model

Oct 28, 2018
Eastern Kentucky University

FACE report for Heavy Equipment Accident

The Ferrel theory states that accidents are the result of a casual chain (as in multiple causation

theory), one or more of the causes being human error, which is in turn caused by three situations

– overload, incompatibility and improper activities. Factors affecting these three situations for

the FACE accident are as follows

Physical environment (Light (visual impairment), noise, and dirt)

- Narrow road with no turn around ability, rushed to finish the assigned task. Some areas

are steep with steep drop off areas.

Incompatibility, mismatch (Physical environment - Mental capability)

- Decided to attempt to back down a steep hill as he was finishing his duties.

Overload, human error (pressure - fatigue - anxiety - emotions)

- Minimal manning with production on halt waiting for him to finish his job duties, it was

the end of the workday; employee was by himself alone at the time of the accident.

Situational (sense of danger, unclear situation). Environment-steepness of slope. Capacity

of training and state of mind, working alone, did not have adequate training for Logging

and Safety requirements to operate heavy equipment specifically wearing a restraint

system or recognizing a defective restraint system.

Incorrect response

- Did not have proper safety equipment on the machine such as functioning seat belts the

seat belt was not worn by the employee. Attempted to back down steep hill instead of

backing out of the area.

- Not waiting until the next work day to get assistance from another employee with

backing out of the construction area

- No pre-use check on the equipment was done

Improper activity by the person

- Not wearing seat belt or having the seatbelt replaced/repaired so it could be worn.

Seatbelt was rusted and in a state of disrepair

- Low perceived probability of accident, he did not know any better since training and

inspections were not conducted for the restraint system

- Working alone with no Supervision

Accident

- Unrestrained heavy equipment operator (victim) died from injuries that occurred when

the dozer he was operating slid backwards and rolled down a steep hill landing on top of

him in a creek.