ACCIDENT

CAUSATION
Protect the Force Through Risk
Management

AC1

Early Man

Protect the Force Through Risk

Management

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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Management

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

Protect the Force Through Risk

Management

AC4

MISTAKES OF PEOPLE

Heinrichs 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.
Protect the Force Through Risk
Management

AC5

Heinrichs Theory
Corrective Action Sequence
(The three Es)

Engineering

Education

Enforcement
Protect the Force Through Risk
Management

AC6

Modern
Causation
Model
OPERATING
ERROR

RESULT:

MISHAP
(POSSIBLE)

-No damage
or injury
-Many fatalities
-Major damage

Protect the Force Through Risk

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.
Protect the Force Through Risk
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

Protect the Force Through Risk
Management

AC11

Modern
Causation
Model
SYSTEM
DEFECTS

OPERATING
ERRORS

RESULT:

MISHAP
(POSSIBLE)

Operating Errors occur because

people make mistakes,
but more importantly,
they occur because of

-No damage
or injury
-Many
fatalities
-Major damage

SYSTEM DEFECTS
Protect the Force Through Risk
Management

AC12

Modern Causation Model

Managers design the Systems
COMMAND
ERROR

SYSTEM
DEFECTS

RESULT:

OPERATING
ERRORS

MISHAP
(POSSIBLE)

-No damage
or injury
-Many
fatalities
-Major damage

System defects occur because of

MANAGEMENT / COMMAND ERROR

Protect the Force Through Risk
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
Protect the Force Through Risk
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
Protect the Force Through Risk
Management

AC15

Modern Causation Model

SAFETY
MANAGEMENT
ERROR

SAFETY
PROGRAM
DEFECT

COMMAND
ERROR

SYSTEM
DEFECT

OPERATING
ERROR

MISHAP

RESULTS
Protect the Force Through Risk
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

1
29
300

SERIOUS
MINOR
CLOSE CALL

RECENT STUDIES

1
59
600

SERIOUS
MINOR
CLOSE CALL

Protect the Force Through Risk

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
Protect the Force Through Risk
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
Protect the Force Through Risk
Management

AC19

Seven Avenues
Potential countermeasures for each modern
causation approach include:

2
1

SAFETY
PROGRAM
DEFECT

3 4 5 6 7

REVISE INFORMATION
COLLECTION
ANALYSIS
IMPLEMENTATION
Protect the Force Through Risk
Management

AC20

Seven Avenues
Potential countermeasures for each modern
causation approach include:

3
1 2

COMMAND
ERROR

4 5 6 7

TRAINING
EDUCATION
MOTIVATION
TASK DESIGN
Protect the Force Through Risk
Management

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
Protect the Force Through Risk
Management

AC22

Seven Avenues
Potential countermeasures for each modern
causation approach include:

5
1 2 3 4

OPERATING
ERROR

6 7

ENGINEERING
TRAINING
MOTIVATION

Protect the Force Through Risk

Management

AC23

Seven Avenues
Potential countermeasures for each modern
causation approach include:

6
1 2 3 4 5

MISHAP

PROTECTIVE EQUIPMENT
BARRIERS
SEPARATION

Protect the Force Through Risk

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

Protect the Force Through Risk

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
Protect the Force Through Risk
Management

AC26

Army Systems Model

TASK
Communication Control
Arrangement
Demands on soldiers
Time aspects

Protect the Force Through Risk

Management

AC27

Army Systems Model

PERSON
Selection

Motivation

Mentally

Positive

Physically

Negative

Emotionally

Retention

Qualified

Protect the Force Through Risk

Management

AC28

Army Systems Model

TRAINING
Types

Targets

Considerations

Initial

Operator

Quality/Quantity

Update

Supervisor

Remedial

Management

Protect the Force Through Risk

Management

AC29

Army Systems Model

ENVIRONMENT
Noise
Weather
Facilities
Lighting
Ventilation
Protect the Force Through Risk
Management

AC30

Army Systems Model

MATERIEL
Supplies
Equipment
Machine Design
Maintenance
Protect the Force Through Risk
Management

AC31

Army Systems Model

SAFETY
MANAGEMENT
ERROR
SAFETY
PROGRAM
DEFECT

COMMAND
ERROR

Army Systems
Model

Task
Training
Environment
Materiel
Person

SYSTEM
DEFECT

RESULT

MISHAP

OPERATING
ERROR

Protect the Force Through Risk

Management

Protect the Force Through Risk

Management

AC33

Protect the Force Through Risk Management

Protect the Force Through Risk

Management

AC34