Module 2: Accident Theories and Unsafe With theories we explain why and how

Acts & Unsafe Conditions things occur as they do.

1. Introduction
4. EVOLUTION OF MODEL OF ACCIDENT
Accident theories guide safety investigations. CAUSATION
They describe the scope of an investigation.
Understanding accident causation is intrinsic
to their successful prevention.
Accident prevention is the most basic of all
safety management paradigms. If safety
management is effective, then there should
be an absence of accidents. Conversely, if
accidents are occurring then effective safety
management must be absent. Therefore,
understanding how accidents occur is
fundamental to establishing interventions to
prevent their occurrence.

2. Learning Outcomes

At the end of the course module the

participants will be able to:

 Outline the theory of accident

causation.
 Identify and Give example of the
Unsafe Acts and Unsafe Condition.
 Outline the types of Accident and
Incident.
 Identify the types of Cost of Accident.

3. Definition of Terms

3.1 Accident - a short, sudden and

unexpected event or occurrence that results
in an unwanted and undesirable outcome and
must directly or indirectly be the result of
human activity rather than a natural event.
3.2 Incident-an unexpected and usually
unpleasant thing that happens.
3.3 Near miss- is an unplanned event that did
not result in injury, illness, or damage – but
had the potential to do so.
3.4 FAULT OF PERSONS - created by social
environment or acquired by ancestry.
3.5 SOCIAL ENVIRONMENT/ANCESTRY -
where
and how a person was raised and educated.
3.6 Theory- collections of concepts
about some real- world area of
concern or interest which facilitate
explaining, predicting, or intervening.
The simple linear models assume that
accidents are the culmination of a series
of events or circumstances which interact
sequentially with each other in a linear
fashion and thus accidents are
preventable by eliminating one of the
causes in the linear sequence.
Complex linear models are based on the
presumption that accidents are a result of
a combination of unsafe acts and latent
hazard conditions within the system
which follow a linear path. The factors
furthest away from the accident are
attributed to actions of the organization
or environment and factors at the sharp
end being where humans ultimately
interact closest to the accident; the
resultant assumption being that
accidents could be prevented by focusing
on strengthening barriers and defenses.
The new generation of thinking about
accident modelling has moved towards
recognizing that accident models need to
be non-linear; that accidents can be
thought of as resulting from combinations
of mutually interacting variables which
occur in real world environments and it is
only through understanding the
combination and interaction of these
multiple factors that accidents can truly
be understood and prevented. (Hollnagel,
2010).

5. Theories of Accident Causation

There are several major theories
concerning accident causation, each of
which has some explanatory and
predictive value.

5.1 The domino theory developed by H.

W. Heinrich

According to Heinrich, an "accident" is one

factor in a sequence that may lead to an
injury. The factors can be visualized as a
series of dominoes standing on edge;
when one falls, the linkage required for a
chain reaction is completed. Each of the
factors is dependent on the preceding
factor.
5.1.1 Heinrich’s Dominos – The Process preceding factors ineffective. He focused on the
human factor, which he termed “Man Failure”, as
1. A personal injury (the final domino) occurs the cause of most accidents.
only as a result of an accident.
2. An accident occurs only as a result of a
personal or mechanical hazard.
3. Personal and mechanical
hazards exist only through the fault of
careless persons or poorly designed or
improperly maintained equipment.
4. Faults of persons are inherited or acquired
as a result of their social environment or
acquired by ancestry.
5. The environment is where and how a
person was raised and educated.
5.1.2 Heinrich’s Domino Theory – Corrective
Action Sequence

[Link] (The three “E”s)

a. Engineering
Control hazards through product design or
process change.

b. Education
Train workers regarding all facets of safety.

Impose on management that attention to

safety pays off.

c. Enforcement
Ensure that internal and external rules,
regulations, and standard operating
procedures are followed by workers as well as
management.

Based on the domino model, accidents could

be prevented by removing one of the factors
and so interrupting the knockdown effect.
Heinrich proposed that unsafe acts and
mechanical hazards constituted the central
factor in the accident sequence and that
removal of this central factor made the
Giving credence to this proposal, (policy, training, etc.)
actuarial analysis of 75,000 insurance
claims attributed some:
 88% of preventable accidents to
unsafe acts of persons
 10% to unsafe mechanical or
physical conditions,
 with the last 2% being
acknowledged as being
unpreventable giving rise to
Heinrich’s chart of direct and
proximate causes

5.2 Human Factors Theory

Heinrich posed his model in terms of a
single domino leading to an accident. The
premise here is that human errors cause
accidents. These errors are categorized
broadly as:
5.2.1 OVERLOAD
The work task is beyond the capability of the
worker
 Includes physical and psychological
factors
 Influenced by environmental
factors, internal factors, and
situational factors
5.2.2 INAPPROPRIATE WORKER RESPONSE
 To hazards and safety measures
(worker’s fault)
 To incompatible workstation
(management, environment
faults)
5.2.3 INAPPROPRIATE ACTIVITIES

 Lack of training and misjudgment of

risk.
 But the structure of this theories
still a cause/effect format.

5.3 Accident/Incident Theory

Extension of human factors theory. Here
the following new elements are
introduced:
5.3.1 Ergonomic traps – These are
incompatible workstations, tools or
expectations (management failure)

5.3.2 Decision to error – Unconscious or

conscious (personal failure)

5.3.3 Systems failure – Management failure

 5.4 Epidemiological Theory Often referred to as behavior-based safety (BBS)

5.4.1 Epidemiology 7.1 Seven (7) basic principles of BBS

This field studies relationship between – Intervention

environmental factors and disease. – Identification of internal factors

Can be used to study causal factors in a

relationship.

[Link] Two key components:

1 Predisposition characteristics-tendencies
may predispose worker to certain actions

2 Situational characteristics-peer pressure,

poor attitude, risk taking

Together these characteristics can cause or

prevent accidents that a person predisposed
to a given situation or condition may
succumb to.

5.5 Systems Theory

Under normal circumstances chances of an

accident is low. Rather than looking at the
environment as being full of hazards and
people prone to errors, system safety
assumes harmony (steady state) exists
between individuals and the work
environment.
5.6 The Energy Release Theory

Developed by Dr. William Haddon, Jr., of the

Insurance Institute for Highway Safety. The
initial statement of the concept of energy
damage in the literature is often attributed to
Gibson but Viner understands it to be a result
of discussions between Gibson, Haddon and
others. The energy damage model is based
on the supposition that “Damage (injury) is a
result of an incident energy whose intensity
at the point of contact with the recipient
exceeds the damage threshold of the
recipient”.
5.7 Behavior Theory
 – Motivation to behave in
the desired manner
– Focus on the positive
consequences of
appropriate behavior
– Application of the scientific
method
– Integration of information
– Planned interventions

5.8 Bird and Germain’s Loss Causation model

They recognized the need for management

to prevent and control accidents in what
were fast becoming highly complex
situations due to the advances in
technology.
They developed an updated domino model
which they considered reflected the
direct management relationship with the
causes and effects of accident loss and
incorporated arrows to show the multi-
linear interactions of the cause and effect
sequence. This model became known as
the Loss Causation Model and was again
represented by a line of five dominos,
linked to each other in a linear sequence

5.9 Combination Theory

 Accidents may/may not fall under

any one model.
 Result from factors in several models.
 One model cannot be applied
to all accidents.

6. Accidents

Accidents are unplanned. An accident is the

final event in an unplanned process that
results in injury or illness to an employee
and possibly property damage. It is the
final result or effect of a number of
surface and root causes.
 An "event," occurs when one
"actor" (one person/thing)
performs an "action" (does
something).

 A person or thing (equipment,

tools, materials, etc.) will do
something that results in a
change of state.

 An accident may be the result

of many factors
(simultaneous, interconnected,
 cross-linked events) that have 12. Over-exposure. Over a period of time, a
interacted in some dynamic way. person is exposed to harmful energy
(noise, heat), lack of energy (cold), or
6.1 Accidents and Incidents
substances (toxic
Workplace accidents are part of a broad group of chemicals/atmospheres).
events or occurrences leading to a physical or
psychological injury. Workplace incidents
adversely affect the completion of a task but
do not result in an employee injury.
6.2 Accident Types

1. Struck-by. A person is forcefully struck

by an object. The force of contact is
provided by the object.
2. Struck-against. A person forcefully
strikes an object. The person provides
the force or energy.
3. Contact-by. Contact by a substance or
material that, by its very nature, is
harmful and causes injury.
4. Contact-with. A person comes in
contact with a harmful substance or
material. The person initiates the
contact.
5. Caught-on. A person or part of his/her
clothing or equipment is caught on an
object that is either moving or
stationary. This may cause the person
to lose his/her balance and fall, be
pulled into a machine, or suffer some
other harm.
6. Caught-in. A person or part of him/her
is trapped, or otherwise caught in an
opening or enclosure.
7. Caught-between. A person is crushed,
pinched or otherwise caught between
a moving and a stationary object, or
between two moving objects.
8. Fall-To-surface. A person slips or trips
and falls to the surface he/she is
standing or walking on.
9. Fall-To-below. A person slips or trips
and falls to a level below the one
he/she was walking or standing on.
10. Over-exertion. A person over-extends
or strains himself/herself while
performing work.
11. Bodily reaction. Caused solely from
stress imposed by free movement of
the body or assumption of a strained
or unnatural body position. A leading
source of injury.
 13. Electrocution 6.4.1 Heinrich’s Indirect & Direct Cost Ratios
14. Fire
 Heinrich wrote that, according to his
research and analysis, an employer’s
6.3 Types of Incident cost of the so-called “incidental”
costs of worker injuries was four
1. Accident - An unplanned, unwanted
times as great as compensation and
event that leads to injury, damage or
medical payments. This 4:1 ratio of
loss. An accident is unplanned. Any indirect to direct costs also appeared
deliberate attempt to cause injury or loss in the three later editions of his book.
is therefore not an accident. Many statements in safety-related
literature repeat Heinrich’s 4-to-1
2. Injury accident - an unplanned,
ratio.
unwanted event that leads to personal
injury of some sort, e.g. a worker on the
ground is struck on the head and killed
by a brick dropped by another worker
from a 5m-high scaffold.

3. Damage-only accident - an unplanned,

unwanted event that leads to damage to
equipment or property,
e.g. a lorry driver misjudges the turning
circle of his vehicle and knocks over a
barrier at the edge of a site entrance,
crushing the barrier beyond repair.

4. Near miss - an unplanned, unwanted

event that had the potential to lead to
injury, damage or loss.

5. Dangerous occurrence - a specified

event that has to be reported to the
relevant authority by statute law.

6. Ill-health incident - an unplanned,

unwanted event that leads to ill-health of
some sort.

6.4 Costs of Accidents

Accidents are more expensive than most

people realize because of the hidden
costs. Some costs are obvious for
example, Workers' Compensation claims
which cover medical costs and indemnity
payments for an injured or ill worker.
These are the direct costs of accidents.
But what about the costs to train and
compensate a replacement worker, repair
damaged property, investigate the
accident and implement corrective
action, and to maintain insurance
coverage? Even less apparent are the
costs related to schedule delays, added
administrative time, lower morale,
increased absenteeism, and poorer
customer relations. These are the indirect
costs.
 [Link] Direct costs are just the tip of the iceberg
 Medical Expenses
7.1 Example of Unsafe Act
 Equipment Damage
 Wasted raw materials 1. Operating equipment without
 Insurance premiums qualification or authorization.
 Litigation Expense
2. Lack of/or improper use of PPE.
[Link] Indirect Cost
3. Operation equipment at unsafe speeds.
 Lost time by injured workers
 Lost time be fellow employees 4. Failure to warn.
 Supervisors time to investigate 5. Bypass or removal of safety devices.
 Training a substitute worker
 Poor efficiency due to break-up of 6. Using defective equipment.
crew
 Hiring cost
 Overtime to make up production 8. Unsafe Conditions
 Failure to meet deadline/fill orders
 Damage to tools and equipment Unsafe condition is an unsatisfactory
 Damage from accident: fire, physical condition existing in a workplace
water, chemicals, explosive, environment immediately before an accident
etc. that was significant in initiating the event.
 Loss of good will
 Loss of production
 Overhead costs while work disrupted
 Downtime

6.5 Iceberg theory of incident costs

Bird (1974) presents the so-called iceberg theory
of incident costs. In an exhibit that suggests
an ice-berg and is captioned “The Real Costs
of Accidents Can Be Measured and
Controlled,” Bird illustrates his ratios of
insured and uninsured costs. Bird and
Germain (1985) use these same ratios but 8.1 Example of Unsafe Condition
add to the descriptions of what costs are 1. Defective equipment: This could include
included in each category. In Bird’s data, the tools and supplies that are defective when
insured costs—medical and compensation they come from the factory or have worn out
costs—are the same as direct costs in some over time and have never been repaired or
other presentations. replaced.
2. Inadequate guards: Many tools are
7. Unsafe Acts inherently dangerous, and guards must be in
place to keep workers from harm.
Unsafe act is any act that deviates
3. Fire hazards: In some cases, there is even
from a generally recognized safe way or
the risk of a serious explosion.
specified method of doing a job and which
increases the probabilities for an accident. 4. Workplace congestion: As the company
grows, the workspace needs to grow with it.
5. Inadequate or broken warning systems:
Workers may not even realize there is a
significant risk of injury until it is too late.
6. Hazardous air conditions: Workers come
away with respiratory issues and other
workplace diseases after being forced to
breathe this contaminated air for shift after
shift.
 7. Lack of cleaning and poor housekeeping:
When the workplace is dirty and cluttered,
injuries
are more likely. For instance, workers could trip on extension cords that were not put away
properly or they could slip and fall on staircases that have never been cleaned.

9. Summary and Conclusion

9.1 Accident prevention is the most basic of all safety management paradigms.

9.2 According to Heinrich Theory:

 88% of preventable accidents to unsafe acts of persons

 10% to unsafe mechanical or physical conditions,
 with the last 2% being acknowledged as being unpreventable giving rise to
Heinrich’s chart of direct and proximate causes

9.3 The two types of cost accident are direct and indirect cost.

9.4 Bird (1974) presents the so-called iceberg theory of incident costs. In an exhibit that
suggests an ice-berg and is captioned “The Real Costs of Accidents Can Be Measured
and Controlled.

9.5 Unsafe act is any act that deviates from a generally recognized safe way or specified
method of doing a job and which increases the probabilities for an accident.

9.6 Unsafe condition is an unsatisfactory physical condition existing in a workplace

environment immediately before an accident that was significant in initiating the event.

Although hidden costs are very real, they are very difficult to demonstrate. To say arbitrarily
to management that they amount to four times the insurable costs is asking for trouble. If
management asks for proof, you can only say, “Heinrich said so.” Management wants
facts, not fantasy. Without proof, hidden costs become fantasy.