Accident Causation

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

2. Causation History • Early man – Accidents were the result of Bad Spirits • Civilized man - Injured person was at fault due to stupidity

4. Causation History • Industrial revolution – carelessness caused accidents. • Natural side effect of production • Cost of doing business • Human nature – people will always be careless

5. Causation History • The court system • 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.

6. Causation History • 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

7. Industrial Revolution “Acts of God” Natural Side Effect of Production ACCIDENTS People Errors Number Is Up Approach Carelessness Employers Rationale for Accidents

8. Heinrich’s Theory • 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.

9. Heinrich’s AccidentCausation Model Social Environment & Ancestry Fault of the Person Unsafe Act Or Unsafe Condition Accident Injury Mistakes of People

10. Accident Causation 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 Accident Injury Mistakes of People

11. Three “E’s” ofAccident Prevention • Engineering • Education • Enforcement

12. Instruction Persuasion Discipline Beyond Engineering

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

14. Modern Causation Model No damage or injury RESULTS Major damage Or fatalities OPERATING ERROR MISHAP

15. Modern Causation Model Disrupted Operation No damage or injury RESULTS Major damage Or fatalities OPERATING ERROR MISHAP RESULTS

16. Modern Causation Model Disrupted Operation Event No damage or injury RESULTS Major damage Or fatalities OPERATING ERROR MISHAP RESULTS

17. Modern Causation Model Failure to properly operate or maintain facilities or equipment Injury or damage Event No damage or injury RESULTS Major damage Or fatalities OPERATING ERROR MISHAP RESULTS

18. Modern Causation Model Single Most Important Addition to New Model System Defect SYSTEM DEFECT No damage or injury RESULTS Major damage Or fatalities OPERATING ERROR MISHAP RESULTS

19. System Defects • 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

20. Modern Causation Model COMMAND/ MANAGEMENT ERROR SYSTEM DEFECT No damage or injury RESULTS Major damage Or fatalities OPERATING ERROR MISHAP RESULTS

21. Management Error • Managers • Design systems • Create procedures • Enforce discipline • Provide training Why does the manager fail to identify system defects or take action?

22. Modern Causation Model SAFETY PROGRAM DEFECT COMMAND/ MANAGEMENT ERROR SYSTEM DEFECT No damage or injury RESULTS Major damage Or fatalities OPERATING ERROR MISHAP RESULTS

23. Safety Program Defect • Ineffective information collection • Weak causation analysis • Poor countermeasures • Inadequate controls • Inadequate programs

24. Modern Causation Model SAFETY MANAGEMENT ERROR SAFETY PROGRAM DEFECT COMMAND/ MANAGEMENT ERROR SYSTEM DEFECT No damage or injury RESULTS Major damage Or fatalities OPERATING ERROR MISHAP RESULTS

25. Safety Management Error • Knowledge • Motivation • Integration • Relevance

27. Accidents & Near Misses Heinrich’s Initial Research Recent Studies 1 Serious 1 Minor 29 59 Near Miss 300 600

28. 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

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

30. SAFETY MANAGEMENT ERROR 1 TRAINING EDUCATION MOTIVATION TASK DESIGN 2 3 4 5 6 7 Seven Avenues Potential Countermeasures

31. SAFETY PROGRAM DEFECT 1 3 4 5 6 7 Seven Avenues Potential Countermeasures 2 REVISE INFORMATION COLLECTION ANALYSIS IMPLEMENTATION

32. TRAINING EDUCATION MOTIVATION TASK DESIGN DISCIPLINE SUPPORT 1 2 4 5 6 7 Seven Avenues Potential Countermeasures 3 COMMAND/ MANAGEMENT ERROR

33. DESIGN REVISION VIA-- - SOP - REGULATIONS - POLICY LETTERS - STATEMENTS 1 2 3 5 6 7 Seven Avenues Potential Countermeasures 4 SYSTEM DEFECT

34. 5 ENGINEERING SAFETY DEVICES WARNING DEVICES TRAINING MOTIVATION 1 2 3 4 6 7 OPERATING ERROR Seven Avenues Potential Countermeasures

35. MISHAP 6 PROTECTIVE EQUIPMENT BARRIERS SEPARATION 1 2 3 4 7 5 Seven Avenues Potential Countermeasures

36. RESULT CONTAINMENT FIREFIGHTING RESCUE EVACUATION FIRST AID 1 2 3 4 5 6 Seven Avenues Potential Countermeasures 7 Systems Model

37. Conclusion The Army approach to accident causation allows us to: • Look beyond the individual • ID the systemic defect • Use the information to develop controls & prevent accidents

38. SAFETY MANAGEMENT ERROR SAFETY PROGRAM DEFECT RESULT MISHAP OPERATING ERROR COMMAND ERROR Army Systems Model Army Systems Model • Task • Person • Training • Environment • Materiel SYSTEM DEFECT

39. 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.

40. Army Systems Model The elements of the Army Systems Model are: • Task • Person • Training • Environment • Materiel

41. Army Systems Model TASK • Communication Control • Arrangement • Demands on soldiers • Time aspects

42. Army Systems Model PERSON Selection • Mentally • Physically • Emotionally • Qualified Motivation • Positive • Negative • Retention

43. Army Systems Model TRAINING Types • Initial • Update • Remedial Targets • Operator • Supervisor • Management Considerations • Quality/Quantity

44. Army Systems Model ENVIRONMENT • Noise • Weather • Facilities • Lighting • Ventilation

45. Army Systems Model MATERIEL • Supplies • Equipment • Machine Design • Maintenance

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

47. RECENT STUDIES SERIOUS 1 MINOR 59 NEAR MISS 600

48. How to analyze the Near Miss • Identify the systemic defect

49. Army System Model Task Training Environment Material Person SYSTEM DEFECT

50. How to analyze the Near Miss • Identify the systemic defect • Identify cause factors: