ACCIDENT

CAUSATION

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Management AC1
Early Man

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Management AC2
 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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Management AC3
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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Management AC4
Heinrich’s Theorems
● 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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Management AC5
Heinrich’s Theory
Corrective Action Sequence
(The three “E”s)
 Engineering
 Education

Enforcement

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Management AC6
Modern
Causation
Model
RESULT:

-No damage
OPERATING MISHAP or injury
ERROR (POSSIBLE)

-Many fatalities
-Major damage

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Management AC7
 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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Management AC8
Examples

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

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Management AC9
Systems Defect

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

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Management AC10
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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Management AC11
Modern
Causation
RESULT:
Model
-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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Management AC12
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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Management AC13
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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Management AC14
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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Management AC15
Modern Causation Model
SAFETY SAFETY
COMMAND
MANAGEMENT PROGRAM
ERROR
ERROR DEFECT

SYSTEM OPERATING
MISHAP
DEFECT ERROR

RESULTS

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Management AC16
Near-Miss Relationship
 Initial studies show for each disabling injury,
there were 29 minor injuries and 300 close
calls/no injury.
 Recent studies indicate for each serious result
there are 59 minor and 600 near-misses.

INITIAL STUDIES RECENT STUDIES

1 SERIOUS 1 SERIOUS

29 MINOR 59 MINOR

300 CLOSE CALL 600 CLOSE CALL

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Management AC17
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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Management AC18
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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Management AC19
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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Management AC20
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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Management AC21
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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Management AC22
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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Management AC23
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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Management AC24
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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Management AC25
Army Systems Model
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.

The elements of the Army Systems Model are:

 Task
 Person
 Training
 Environment
 Materiel

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Management AC26
Army Systems Model

TASK
• Communication Control
• Arrangement
• Demands on soldiers
• Time aspects

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Management AC27
Army Systems Model
PERSON
Selection Motivation
• Mentally • Positive
• Physically • Negative
• Emotionally • Retention
• Qualified

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Management AC28
Army Systems Model

TRAINING
Types Targets Considerations
• Initial • Operator • Quality/Quantity
• Update • Supervisor
• Remedial • Management

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Management AC29
Army Systems Model
ENVIRONMENT
• Noise
• Weather
• Facilities
• Lighting
• Ventilation

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Management AC30
Army Systems Model

MATERIEL
• Supplies
• Equipment
• Machine Design
• Maintenance

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Management AC31
Army Systems Model
SAFETY Army Systems
MANAGEMENT Model RESULT
ERROR • Task
• Training
• Environment
SAFETY • Materiel
PROGRAM • Person MISHAP
DEFECT

COMMAND SYSTEM OPERATING

ERROR DEFECT ERROR

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Management
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Management AC33
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Management AC34