Accident CausationWhy Do We Have Accidents?Updated 1 July 2014

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Causation HistoryEarly man Accidents were the result of Bad Spirits

Civilized man - Injured person was at fault due to stupidity

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Causation HistoryIndustrial revolution carelessness caused accidents. Natural side effect of productionCost of doing businessHuman nature people will always be careless

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Causation HistoryThe court systemUpheld the view of individual responsibility Injured worker had to sueEmployer 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.

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Causation HistoryEmployers take noticeFinancial responsibility for an injured worker More cost effective to prevent accidents. Only theory remained personal carelessness Safety program success was hit and miss

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Industrial RevolutionNatural Side Effect of ProductionActs of GodACCIDENTSNumber Is Up ApproachPeople ErrorsCarelessnessEmployers Rationale for Accidents

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Heinrichs TheoryScientific Approach Heinrichs 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.

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Heinrichs AccidentCausation ModelInjuryAccidentUnsafe ActOrUnsafeConditionFault of the PersonSocial Environment& AncestryMistakes of People

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Accident CausationSocialEnvironmentAnd AncestryFault of thePerson(Carelessness)Unsafe ActOrConditionAccidentInjury1932 - First Scientific Approach To Accident Prevention H.W. HeinrichIndustrial Accident PreventionMistakes of People

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Three Es ofAccident PreventionEngineering

Education

Enforcement

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Beyond EngineeringInstruction

Persuasion

Discipline

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Modern Causation ModelParallels Heinrichs theoryInjury becomes ResultVaries from no damage to very severeAccident becomes MishapInjury not requiredUnsafe Act or Unsafe Condition becomes Operating ErrorAct and condition captured as error

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Modern Causation ModelOPERATINGERRORMISHAPNo damage or injury

RESULTS

Major damageOr fatalities

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Modern Causation ModelOPERATINGERRORMISHAPRESULTSDisrupted OperationNo damage or injury

RESULTS

Major damageOr fatalities

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Modern Causation ModelOPERATINGERRORMISHAPRESULTSEventNo damage or injury

RESULTS

Major damageOr fatalitiesDisrupted Operation

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Modern Causation ModelOPERATINGERRORMISHAPRESULTSInjury or damageEventFailure to properly operate or maintainfacilities or equipment No damage or injury

RESULTS

Major damageOr fatalities

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Modern Causation ModelSYSTEMDEFECTOPERATINGERRORMISHAPRESULTSSingle Most Important Addition to New ModelSystem DefectNo damage or injury

RESULTS

Major damageOr fatalities

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System DefectsWeaknesses in the way the system is designed or operatedImproper assignment of responsibilitiesImproper climate of motivationInadequate training and educationInadequate or improper equipment or suppliesPoor personnel selection for jobInadequate funding

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Modern Causation Model OPERATINGERRORMISHAPRESULTSNo damage or injury

RESULTS

Major damageOr fatalitiesCOMMAND/MANAGEMENTERRORSYSTEMDEFECT

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Management ErrorManagersDesign systemsCreate proceduresEnforce disciplineProvide trainingWhy does the manager fail to identify system defects or take action?

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Modern Causation Model OPERATINGERRORMISHAPRESULTSNo damage or injury

RESULTS

Major damageOr fatalitiesSAFETYPROGRAMDEFECTCOMMAND/MANAGEMENTERRORSYSTEMDEFECT

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Safety Program DefectIneffective information collection

Weak causation analysis

Poor countermeasures

Inadequate controls

Inadequate programs

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Modern Causation Model SAFETYPROGRAMDEFECTCOMMAND/MANAGEMENTERRORSYSTEMDEFECTOPERATINGERRORMISHAPRESULTSNo damage or injury

RESULTS

Major damageOr fatalitiesSAFETYMANAGEMENTERROR

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Safety Management ErrorKnowledgeMotivationIntegrationRelevance

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Accidents & Near Misses129300159600Heinrichs InitialResearchRecentStudiesSeriousMinorNear Miss

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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 ResultSeven Avenues

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Modern Causation Model SAFETYPROGRAMDEFECTCOMMAND/MANAGEMENTERRORSYSTEMDEFECTOPERATINGERRORMISHAPRESULTSNo damage or injury

RESULTS

Major damageOr fatalitiesSAFETYMANAGEMENTERROR7654321

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Seven AvenuesPotential Countermeasures

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Seven AvenuesPotential CountermeasuresREVISE INFORMATIONCOLLECTIONANALYSISIMPLEMENTATION2

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Seven AvenuesPotential Countermeasures3COMMAND/MANAGEMENTERROR

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Seven AvenuesPotential CountermeasuresSYSTEMDEFECT4

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Seven AvenuesPotential Countermeasures

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Seven AvenuesPotential Countermeasures

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Seven AvenuesPotential Countermeasures7Systems Model

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Conclusion

The Army approach to accident causation allows us to:

Look beyond the individualID the systemic defectUse the information to develop controls & prevent accidents

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Army Systems ModelSYSTEMDEFECTArmy SystemsModelTaskPersonTrainingEnvironmentMateriel

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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

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The elements of the Army Systems Model are:TaskPersonTrainingEnvironmentMaterielArmy Systems Model

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TASKArmy Systems ModelCommunication ControlArrangementDemands on soldiersTime aspects

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PERSONArmy Systems ModelSelectionMentallyPhysicallyEmotionallyQualifiedMotivationPositiveNegativeRetention

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Army Systems ModelTRAININGTypesInitialUpdateRemedialTargetsOperatorSupervisorManagementConsiderationsQuality/Quantity

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Army Systems ModelENVIRONMENTNoise

Weather

Facilities

Lighting

Ventilation

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Army Systems ModelMATERIELSupplies

Equipment

Machine Design

Maintenance

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DA PAM 385-403 Ws Approach to Information Collection, Analysis and Recommendations

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1RECENT STUDIESSERIOUSMINORNEAR MISS59600

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How to analyze the Near Miss

Identify the systemic defect

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SYSTEM DEFECTArmy System ModelTaskTrainingEnvironmentMaterial

Person

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How to analyze the Near Miss

Identify the systemic defectIdentify cause factors:

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Cause Factors

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How to analyze the Near Miss

Identify the systemic defectIdentify cause factors:Human, Materiel, EnvironmentalIf human Identify the system inadequacies, the root causeLeader, Training, Standards, Support, Individual

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System Inadequacies

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Near Miss - Summary

Identify the systemic defectIdentify cause factors:Human, Materiel, EnvironmentalIf human Identify the system inadequacies and root causeLeader, Training, Standards, Support, Individual

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*USASC conducted a study of cause factors based on class A-C accidents from FY99-FY01. The results indicate that, although the percentages differ, the top four causes of accidents in Aviation and Ground are the same: indiscipline, leadership, training and standards. These categories are explained in general terms below.Indiscipline-- The soldier knew what to do, but chose an incorrect action because of habit, attitude, or mental lapse.Leadership-- Someone in the chain of command failed to inform, motivate, plan, or correct the soldiers action.Training-- The soldier was not taught, or made to remember, the correct action.Standard-- No one thought up, or wrote down, the correct action.

* Heinrich began with the fact of injury and traced it back to its causes. An injury, he reasoned, was caused by an accident, and an accident was caused by either an unsafe act on the part of the injured person or an unsafe condition in the environment. The next step back in Heinrichs accident causation model again placed blame squarely on the individual and then, in the next step makes a vague reference to the persons social environment and ancestry as the causation reason for his carelessness or fault. This was a major breakthrough because it removed some of the blame from the individual worker. The worker might have been careless but it might have been caused because the machine was poorly designed or maintained, thus making it likely whoever worked with it would be injured. Managers could see the rationale behind the theory. Since one of the remedies against accidents dealt with things instead of people, employers had something concrete to correct. Machines, business and factory layouts were looked at with a new eye and were found to be sadly lacking in safety features. A big push began to engineer for safety. This engineering for safety has been very effective and still is a big area of responsibility under the Occupational Safety and Health Act. However, engineering out unsafe conditions was only part of Mr. Heinrichs corrective action sequence. The other three pillars included: Instruction Workers taught how to do their job safely Persuasion and appeal people were exhorted to behave safely Discipline Worker threatened with loss of money or job if performance did not improve*From Heinrichs theory came the three Es as we know them today.*However, engineering out unsafe conditions was only part of Mr. Heinrichs corrective action sequence. The other three pillars included: Instruction Workers taught how to do their job safely Persuasion and appeal people were exhorted to behave safely Discipline Worker threatened with loss of money or job if performance did not improve*Addition of system defects breaks away from Heinrich and adds concept that virtually revolutionizes accident prevention.

This key concept is the single most important concept yet developed in acident prevention theory, it changes what we seek to do and how we do it. *Safety program defectA defect in some aspect of the safety program that allows an avoidabl error to exist.Ineffective information collectionWeak causation analysisPoor countermeasuresInadequate controls They fail to implement the 5th step of the RM process.Inadequate programs *Safety management errorA weakness in the knowledge or motivation of the safety manager that permits a preventable defect in the safety programKnowledgeMotivationIntegrated into command (primary staff)Relevance mission oriented and realistic**Heinrichs study in an industrial setting

Data displayed a near miss relationship between serious, minor and near miss mishaps. The initial study showed that for every serious injury there were 29 minor and 300 near miss incident.

Later studies discovered the same relationship but the data showed 59 minor injuries and 600 near misses for every 1 serious accident.

The bottom line is investigating minor and near miss incidents may provide the insight to create strategies to avoid the 1 serious accident.*******