ACCIDENT CAUSATION
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AC1
Early Man
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AC2
Industrial Revolution
Factory managers reasoned that workers were hurt because — Number is Up Carelessness People Error
ACCIDENT
Act of God Cost of doing Business PEOPLE PROBLEM
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AC3
Domino Theory
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
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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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AC5
Heinrich’s Theory
Corrective Action Sequence (The three ―E‖s)
Engineering
Education
Enforcement
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AC6
Modern Causation Model
RESULT: -No damage or injury OPERATING ERROR MISHAP (POSSIBLE)
-Many fatalities -Major damage
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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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AC8
Examples
Operating Errors:
Being in an unsafe position
Stacking supplies in unstable stacks
Poor housekeeping Removing a guard
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AC9
Systems Defect
Revolutionized accident prevention A weakness in the design or operation of a system or program
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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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AC11
Modern Causation Model
SYSTEM DEFECTS
RESULT: -No damage or injury
OPERATING ERRORS
MISHAP (POSSIBLE)
-Many fatalities -Major damage
Operating Errors occur because people make mistakes, but more importantly, they occur because of
SYSTEM DEFECTS
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AC12
Modern Causation Model
Managers design the Systems
COMMAND ERROR
RESULT:
-No damage or injury
SYSTEM DEFECTS
OPERATING ERRORS
MISHAP (POSSIBLE) -Many fatalities -Major damage
System defects occur because of
MANAGEMENT / COMMAND ERROR
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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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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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AC15
Modern Causation Model
SAFETY MANAGEMENT ERROR
SAFETY PROGRAM DEFECT COMMAND ERROR
SYSTEM DEFECT
OPERATING ERROR
MISHAP
RESULTS
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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
29 300
SERIOUS
MINOR CLOSE CALL
1 59 600
SERIOUS MINOR CLOSE CALL
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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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AC18
Seven Avenues
Potential countermeasures for each modern causation approach include:
1
SAFETY MANAGEMENT ERROR
TRAINING EDUCATION MOTIVATION TASK DESIGN
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2 3 4 5 6 7
AC19
Seven Avenues
Potential countermeasures for each modern causation approach include:
2
1
SAFETY PROGRAM DEFECT
REVISE INFORMATION COLLECTION ANALYSIS IMPLEMENTATION
3 4 5 6 7
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AC20
Seven Avenues
Potential countermeasures for each modern causation approach include:
3
1 2
COMMAND ERROR
TRAINING EDUCATION MOTIVATION TASK DESIGN
4 5 6 7
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AC21
Seven Avenues
Potential countermeasures for each modern causation approach include:
4
1 2 3
SYSTEM DEFECT
5 6 7
DESIGN REVISION VIA-- SOP - REGULATIONS - POLICY LETTERS - STATEMENTS
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AC22
Seven Avenues
Potential countermeasures for each modern causation approach include:
5
1 2 3 4
OPERATING ERROR
ENGINEERING TRAINING MOTIVATION
6 7
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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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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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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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AC26
Army Systems Model
TASK
• Communication Control
• Arrangement • Demands on soldiers • Time aspects
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AC27
Army Systems Model
PERSON
Selection • Mentally • Physically • Emotionally • Qualified Motivation • Positive • Negative • Retention
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AC28
Army Systems Model
TRAINING
Types
• Initial
• Update • Remedial
Targets
• Operator
• Supervisor • Management
Considerations
• Quality/Quantity
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AC29
Army Systems Model
ENVIRONMENT
• Noise
• Weather
• Facilities • Lighting • Ventilation
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AC30
Army Systems Model
MATERIEL
• Supplies • Equipment • Machine Design
• Maintenance
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AC31
Army Systems Model
SAFETY MANAGEMENT ERROR SAFETY PROGRAM DEFECT Army Systems Model
• • • • • Task Training Environment Materiel Person
RESULT
MISHAP
COMMAND ERROR
SYSTEM DEFECT
OPERATING ERROR
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AC33
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AC34