6.0 Ch03 AccidentTheories EDIT B 25 Nov 2015

ACCIDENT
CAUSATION
THEORIES
Chapter 3
1
Accidents in Construction
Why do accidents happen in construction?
Physical hazards
Environmental hazards
Human factors
No safety regulations or poor ones
Poor communication within, between, and among various
trades working on a job site
Accidents should not be viewed as inevitable just
because hazards exist.
For every accident that occurs, there is a cause.
Chapter 3
2
Theories of Accident Causation
The most widely known theories of accident
causation:
1) Domino theory
2) Human factors theory
3) Accident / incident theory
4) Epidemiological theory
5) Systems theory
6) Combination theory
7) Behavioral theory
Chapter 3
3
causation:
1) Domino theory
5) Systems theory
Chapter 3
4
Domino Theory
Herbert W. Heinrich Travelers Insurance Company
In the late 1920s, studying reports of 75,000 workplace
accidents, he concluded the following:
88% of accidents are caused by unsafe acts committed by fellow workers
10% of accidents are caused by unsafe conditions
2% of accidents are unavoidable
Contemporary research considers domino theory as
outdated however todays more widely accepted theories
can be traced back to Heinrichs study.
Chapter 3
5
Domino Theory
1932 First Scientific Approach to
Accident/Prevention - H.W. Heinrich
Industrial Accident Prevention
Social Fault of the Unsafe Act

Environment Person or Accident Injury
and Ancestry (Carelessness) Condition
MISTAKES OF PEOPLE Chapter 3

Domino Theory
Axioms of Workplace Safety
Conclusions laid foundation for Axioms of
Industrial Safety (came to be known as the
Domino Theory)
1. Injuries result from a completed series of factors, one of which
is the accident itself.
2. An accident can occur only as the result of an unsafe act by a
person or a physical or mechanical hazard, or both.
3. Most accidents are the result of unsafe behavior by people.
4. An unsafe act by a person or an unsafe condition does not
always immediately result in an accident or injury.
5. The reasons why people commit unsafe acts can serve as helpful
guides in selecting corrective actions.
6. The severity of an accident is largely fortuitous, and the accident
that caused it is largely preventable.
Chapter 3
7
Axioms of Workplace Safety
7. The best accident prevention techniques are analogous with the
best quality and productivity standards.
8. Management should assume responsibility for safety because it
is in the best position to get results.
9. The supervisor is the key person in the prevention of workplace
accidents.
10. In addition to the direct costs of an accident (i.e., compensation,
liability claims, medical costs, and hospital expenses), there are
also hidden or indirect costs.
Heinrich believed any safety programs taking all
10 axioms into consideration will likely be
effective.
Chapter 3
CEE 698 Construction Health and Safety
8
Domino Theory
Five factors in sequence leading to an accident:
1. Ancestry and social environment. Negative character traits that
may lead people to behave in an unsafe manner can be inherited
(ancestry) or acquired as a result of the social environment.
2. Fault of person. Negative character traits, whether inherited or
acquired, are why people behave in an unsafe manner and why
hazardous conditions exist.
3. Unsafe acts and mechanical or physical hazards. Unsafe acts
committed by people and mechanical or physical hazards are the
direct causes of accidents.
4. Accident. Typically, accidents that result in injury are caused by
falling or being hit by moving objects.
5. Injury. Typical injuries resulting from accidents include
lacerations and fractures.
Chapter 3
9
Domino Theory
Two central points:
Injuries are caused by preceding factors
By removing the unsafe act or hazardous condition,
the action of these preceding factors is negated and
the accidents/injuries are prevented.
Chapter 3
10
Domino Theory - Example
Construction Products Company (CPC) is a
distributor of lumber, pipe and concrete products.
Warehouse personnel load most of the orders by
hand therefore they are required to wear personal
protective gear.
Management observed increases in minor injuries
among personnel during summer months.
However during the last summer they suffered
from the serious back injuries of two workers.
Chapter 3
11
Investigation revealed a series of events and
a central causal behavior which created a
domino effect.
Personal protective gear becomes uncomfortable
due to hot weather and loaders take it off.
This situation increases the number of minor
injuries but management does not pay attention due
to the nature of injuries. Therefore it was probably
inevitable to suffer from more serious injuries.
Chapter 3
12
Solution:
Removing the causal factor - the failure of warehouse personnel to use
their personal protective gear during summer months.
Forming a committee.
Committees recommendations:
1. Provide all warehouse personnel with training on the importance and
proper use of personal protection
2. Require warehouse supervisors to monitor the use of personal protection
gear more closely
3. Establish a company policy that contains specific and progressive
disciplinary measures for failure to use required personal protection gear
4. Implement several heat reduction measures to make warehouses cooler.
Chapter 3
13
causation:
1) Domino theory

5) Systems theory
Chapter 3
14
Human Factors Theory
Attributes accidents to a chain of events
ultimately caused by human error.
Consists of three broad factors that lead to
human error:
Overload
Inappropriate Response
Inappropriate Activities
Chapter 3
15
Factors Leading to Human Error
Overload
Inappropriate Inappropriate
Activities Human Error Factors
Response
Chapter 3
16
Overload
Capacity product of such factors as a persons natural
ability, training, state of mind, fatigue, stress, and physical
condition.
Load consisting of tasks for which a person is
responsible and added burdens resulting from
environmental factors (noise, heat), internal factors
(personal problems, stress), and situational factors (unclear
instructions).
State the product of a persons motivational levels.
Overload an imbalance between a persons capacity at a
any given time and the load that the person is carrying in a
given state.
Chapter 3
17
Inappropriate Response or
Incompatibility
How a person responds to a given situation can
cause or prevent an accident.
Inappropriate response occurs when:
A person detects a hazardous condition but does
nothing to correct it
A person disregards an established safety procedure.
Incompatibility of a persons workstation with
regard to size, force, reach, feel and similar factors
can lead to accidents and injuries.
Chapter 3
18
Inappropriate Activities
Human error can be result of inappropriate
activities.
Examples:
Person who undertakes a task that he / she does not
know how to do.
A person who misjudges the degree of risk
involved in a given task and proceeds on that
misjudgment.
Chapter 3
19
Chapter 3
20
Overload Inappropriate Inappropriate
Environmental Response Activities
Detecting a
Factors (noise, Performing tasks
distractions hazard but not
without the
correcting it
Internal Factors requisite training
Removing
(personal problems, Misjudging the
emotional stress) safeguards from
degree of risk
machines and
Situational Factors involved with a
equipment
(unclear given task
instructions, risk Ignoring safety
level)
Chapter 3
Human Factors Theory -
Example
Jones Cabinets & Construction Company
sees rapid growth in sales which
overwhelmed companys work force.
New teams of cabinet makers and installers
hired.
Authorized unlimited overtime.
Numbers of accidents and injuries
increased.
Chapter 3
22
Human Factors Theory -
Example
Investigation revealed human errors in the
three categories:
Overload:
Employees working beyond their personal limits and beyond
their capabilities.
Stress, insufficient training and fatigue
Inappropriate response:
Carpenters removing the safeguards to speed up construction.
Inappropriate activities:
Assigning employees to duties for which they are not fully
trained
Chapter 3
23
causation:
1) Domino theory

5) Systems theory
Chapter 3
24
Accident / Incident Theory
Extension of human factors theory
Developed by Dan Petersen
New elements:
Ergonomic traps
The decision to err
Systems failures
Chapter 3
25
Accident/Incident Theory
Chapter 3
26
Petersens Accident/Incident
Theory
Overload Ergonomic Traps Decision to
Pressure Err
Incompatible Misjudgment of
Fatigue workstation (i.e. the risk
Motivation size, force, reach, Unconscious
feel) desire to err
Drugs
Incompatible Logical decision
Alcohol expectations based on the
Worry situation
Human Error
Systems Failure
Policy Inspection Acciden
Responsibility Correction t
Training Standards
Injury/Damage Chapter 3
Accident / Incident Theory
Some of the reasons why systems may fail:
1. Management does not establish a comprehensive
safety policy
2. Responsibility and authority with regard to safety
are not clearly defined
3. Safety procedures, such as measurement, inspection,
correction, and investigation, are ignored or given
insufficient attention.
4. Employees do not receive proper orientation
5. Employees are not given sufficient safety training
Chapter 3
28
Accident / Incident Theory -
Example
Panhandle Precast Concrete has developed a well-
earned reputation as a safe company.
When the safety manager of the firm, Jack Bond,
was elected as the president of a statewide safety
organization, safety problems within the firm
began.
Jack Bond neglected his duties at PPC.
Workers stopped following the safety precautions
once they realized he had stopped observing and
correcting them.
Chapter 3
29
causation:
1) Domino theory
5) Systems theory
Chapter 3
30
Epidemiological Theory
Epidemiology: Study of causal relationships
between environmental factors and disease.
Epidemiological theory holds that the models used
for studying and determining these relationships
can also be used to study casual relationships
between environmental factors and accidents.
Components:
Predisposition Characteristics
Situational Characteristics
Chapter 3
31
Chapter 3
32
Predisposition Situational
Characteristics Characteristics
Risk assessment by
Susceptibility of people individuals
Perceptions Peer pressure
Environmental factors Priorities of the
supervisor
Attitude
Can cause or prevent

accident conditions
Chapter 3
Epidemiological Theory -
Example
Jane Andrews was the newest member of the loading unit
for Construction Products, Inc.
She had 2 days of training on proper lifting techniques
before beginning the work and mandatory use of back-
support belts
Her supervisor and colleagues pressured to disregard the
proper lifting methods she learned in training.
She followed her supervisor and after 2 months had to
undergo major surgery to repair two ruptured disks.
Predisposition factor: Her susceptibility to pressure from
her coworkers and supervisor
Situational factors: Peer pressure and priorities of Chapter 3
supervisor 34
causation:
1) Domino theory
5)Systems theory
Chapter 3
35
Systems Theory
System a group of regularly interacting and interrelated
components that together form a unified whole.
An accident may occur as a system which is composed of:
Person
Machine
Environment
The likelihood of an accident to occur is determined by how
these components interact.
Example: A worker who temporarily replaces an experienced
crane operator increases the probability of an accident.
Chapter 3
36
Systems Theory Model
Machine Person Task to be

Collect Weigh risks
Make
performed
information decision
Environment
Interaction
Chapter 3
Systems Theory
The primary components of the systems model are
the person, machine, environment, and information;
decisions; risks; and the task to be performed.
Each of these components has a bearing on the
probability that an accident will occur.
Chapter 3
38
Systems Theory
Factors which should be considered before
collecting information, weighing risks and
making a decision:
job requirements
the workers abilities and limitations
the gain if the task is successfully accomplished
the loss if the task is attempted but fails
the loss if the task is not attempted
Chapter 3
39
Systems Theory - Example
Construction Service Company (CSC) makes customized trusses
for residential construction jobs.
Workers including the apprentices use manually operated
machines which causes two problems:
It is difficult for even experienced workers to make clean accurate cuts
Machines are so old that they frequently break down.
While working under a major contract, an apprentice gets
careless and runs his hand into the saw blade.
The person-machine-environment chain:
Person involved was inexperienced.
Machine involved was old and prone to breakdown
The environment was stressful and pressure-packed.
Chapter 3
40
causation:
1) Domino theory
5) Systems theory
6)Combination theory
Chapter 3
41
Combination Theory
Often the cause of an accident cannot be
adequately described by one theory.
Differences between the theory and reality
may exist.
Combination theory helps explain the actual
cause of an accident by combining different
parts of several theories.
Chapter 3
42
Combination Theory - Example
Crestview Construction Company (CCC) maintains
four large warehouses .
Ventilation of these warehouses are important and the
vent filters need to be changed periodically.
Changing the vents filter involves two potential
hazards:
Unvented dust and fumes can make breathing difficult.
Vents are located 110 feet above the ground level, which
can be accessed through a narrow cat walk that has knee-
high guardrails.
Chapter 3
43
Combination Theory - Example
CCC has well defined rules which are strictly enforced.
However an employee fell from the catwalk while he was trying
to change one of the filter. His lifeline held him for 20 minutes.
When he panicked and tried to pull himself up he knocked the
buckle of his safety harness open and fell to the concrete floor,
breaking his neck.
Critical factors:
Absence of supervisor
Inexperience of worker
A conscious decision by the worker to disregard the safety
procedures
A faulty buckling mechanism on the safety harness
An unsafe design (only a knee-high guardrail on the catwalk)
Chapter 3
44
causation:
1) Domino theory
5) Systems theory
7)Behavioral theory Chapter 3
45
Behavioral Theory
Referred to as Behavior-based safety
(BBS)
E. Scott Geller Safety Performance
Solutions, Inc., and professor of
psychology
Believes in 7 basic principles of BBS:
1. Use intervention that is focused on employee
behavior.
2. Identify external factors that aid in understanding
and improving employee behavior.
Chapter 3
46
Behavioral Theory
3. Direct behavior with activator or events antecedent to
the desired behavior, and motivate employees to
behave as desired with incentives and rewards that
follow desired behavior.
4. Focus on the positive consequences that result from
the desired behavior as a way to motivate employees.
5. Apply scientific method to improve attempts at
behavioral interventions.
6. Use theory to integrate information rather than to
limit possibilities.
7. Plan interventions with the feelings and attitudes of
the individual employee in mind.
Chapter 3
47
BBS and ABC Model
Behavior-based safety trainers and consultants
teach the ABC model (or three-term
contingency) as a framework to understand and
analyze behavior or to develop interventions
for improving behavior. As given in BBS
principle 3the A stands for activators or
antecedent events that precede behavior (B),
and C refers to the consequences following
behavior or produced by it. Activators direct
behavior, whereas consequences motivate
behavior.
Chapter 3
48
BBS and ABCO Model
Outcome refers to the longer-term results of engaging
in safe or unsafe behavior. For example, an
antecedent of a sign requiring employees to wear
safety goggles could produce the behavior of putting
on the goggles, the consequence of avoiding an eye
injury, and the outcome of being able to continue
working and enjoying time with the family. One the
other hand, the consequence of not wearing goggles
could be an eye injury with a potential outcome of
blindness, time off the job, and a reduced quality of
life. Failure to address the issue of outcomes
represents a lost opportunity to give employees a
good reason for engaging in safe behaviors.
Chapter 3
49
Behavioral Theory - Example
Jack Coker decided to apply the ABC model in
turning the unsafe behavior pattern of the workers
(not wearing hard hats) in Bonded Builders, Inc.
1. He removed the old Hard Hat Area signs and
replaced them with newer, more noticeable signs.
2. He scheduled a brief seminar on head injuries in which
he told a story of two employees. One was in a hospital
bed surrounded by family members he did not even
recognize; the other was shown enjoying a family
outing with happy family members.
Chapter 3
50
Modern Causation Model
Definition - What does Accident Causation mean?

Accident causation refers to the factors that are the primary reasons
behind an accident. For occupational health and safety
professionals, determining causation factors in any workplace
injury or accident is key. Understanding what caused an unsafe
situation to occur is important in implementing measures to help
prevent a reoccurrence.
Chapter 3
51
RESULT:
-No damage
OPERATING MISHAP or injury
ERROR (POSSIBLE)
-Many fatalities
Operating Errors occur because -Major damage
people make mistakes,
but more importantly,
they occur because of
SYSTEM DEFECTS Chapter 3

Managers design the Systems
COMMAND
ERROR RESULT:
-No damage
or injury
SYSTEM OPERATING MISHAP
DEFECTS ERRORS (POSSIBLE)
-Many fatalities
-Major damage
System defects occur because of

MANAGEMENT / COMMAND ERROR
Chapter 3
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
Chapter 3
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
Chapter 3
SAFETY SAFETY
COMMAND
MANAGEMENT PROGRAM
ERROR
ERROR DEFECT
SYSTEM OPERATING
MISHAP
DEFECT ERROR
RESULTS
Chapter 3
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 SERIOUS 1 SERIOUS
29 MINOR 59 MINOR
300 CLOSE CALL 600 CLOSE CALL
Chapter 3
Iceberg Principle
Outcomes (Consequences)
Incident (Accident)
Causal Factor
Causal Factor
Causal Factor
Primary Causal Factor

Chapter 3
Seven Avenues
There are seven avenues through which we can
initiate countermeasures. They are:
Safety management error
Safety program defect
Management / Command error
System defect
Operating error
Mishap
Result
Chapter 3
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
Chapter 3
Seven Avenues
2
SAFETY
1 PROGRAM
DEFECT
3 4 5 6 7
REVISE INFORMATION
COLLECTION
ANALYSIS
IMPLEMENTATION
Chapter 3
Seven Avenues
3
COMMAND
1 2 ERROR 4 5 6 7
TRAINING
EDUCATION
MOTIVATION
TASK DESIGN
Chapter 3
Seven Avenues
4
SYSTEM
1 2 3 DEFECT 5 6 7
DESIGN REVISION VIA--
- SOP
- REGULATIONS
- POLICY LETTERS
- STATEMENTS
Chapter 3
Seven Avenues
5
OPERATING
1 2 3 4 ERROR 6 7
ENGINEERING
TRAINING
MOTIVATION
Chapter 3
Seven Avenues
6
1 2 3 4 5 MISHAP 7
PROTECTIVE EQUIPMENT
BARRIERS
SEPARATION
Chapter 3
Seven Avenues
7
1 2 3 4 5 6 RESULT
CONTAINMENT
FIREFIGHTING
RESCUE
EVACUATION
FIRST AID
Chapter 3
Human Factors Model
SAFETY Human Factors
MANAGEMENT Model RESULT
ERROR Tasks
Tools/Tech
Environment
SAFETY Organization
PROGRAM Person MISHAP
DEFECT
COMMAND OPERATING
ERROR ERROR
Chapter 3
Estimating the cost of
accident
To have value, a cost estimate must relate
directly to the specific company in question.
Applying broad industry cost factors will not
suffice.
To arrive at company-specific figures, divide
costs associated with an accident be into
insured & uninsured costs.
Determining insured costs of accidents is a
matter of examining accounting records.
Chapter 3
68
calculate uninsured costs
To calculate uninsured costs, divide accidents into the
following four classes:
Class 1 accidents - lost workdays, permanent partial
disabilities, and temporary total disabilities.
Class 2 accidents - treatment by a physician outside
the company's facility.
Class 3 accidents- locally provided first aid, property
damage less than $100, or loss of less than eight hours
of work time
Class 4 accidents - injuries so minor they require no
physician attention, property damage of $100 or less, or
eight or fewer work hours lost.
Chapter 3
69
FIGURE 25 Uninsured costs worksheet.
Chapter 3
Other Cost-Estimation
Methods
Costs associated with workplace accidents, injuries, &
incidents fall into broad categories such as:
Lost work hours; Medical costs.
Property damage; Fire losses.
Insurance premiums and administration; Indirect costs.
Compile total number lost hours for the period and multiply
times the applicable loaded labor rate.
The employee's hourly rate plus benefits.
Subtotal cost is medical costs, insurance premiums, property

damage & fire losses for the period.
Increased by a standard percentage for indirect costs, to
determine total cost of accidents for a specific period.
Chapter 3
Estimating the hidden
Cost
Accident costs are like an iceberg, in that the larger part
of the actual cost is hidden beneath the surface.
There is usually a great deal of activity when a serious
accident occurs.
There may be a slowdown in production near the site.
There is usually a great deal of activity when a serious
accident occurs.
There also will be a need to replace the injured worker.
Costs associated with the learning curve of the replacement.
The supervisor & accident investigation team probably will
need to spend time conducting an investigation.
Chapter 3
72
Estimating the hidden Cost
FIGURE 26 Some accident costs that might be overlooked.
Chapter 3

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ACCIDENT

Social Fault of the Unsafe Act

MISTAKES OF PEOPLE Chapter 3

2) Human factors theory

3) Accident / incident theory

Can cause or prevent

Machine Person Task to be

7)Behavioral theory Chapter 3

Definition - What does Accident Causation mean?

SYSTEM DEFECTS Chapter 3

System defects occur because of

Ineffective Information Collection

INITIAL STUDIES RECENT STUDIES

Primary Causal Factor

Subtotal cost is medical costs, insurance premiums, property

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