2. Protect the Force Through Risk Management AC1 ACCIDENT CAUSATION

3. Protect the Force Through Risk Management AC2 Early Man

4. Protect the Force Through Risk Management AC3 Factory managers reasoned that workers were hurt because — ACCIDENT PEOPLE PROBLEM Industrial Revolution Number is Up People ErrorCarelessness Act of God Cost of doing Business

5. Protect the Force Through Risk Management AC4 “Industrial Accident Prevention” 1932 First Scientific Approach to Accident/Prevention - H.W. Heinrich. Domino Theory Social Environment and Ancestry Fault of the Person (Carelessness) Unsafe Act or Condition Accident Injury MISTAKES OF PEOPLE

6. Protect the Force Through Risk Management AC5 Heinrich’s Theorems l INJURY - caused by accidents. l ACCIDENTS - caused by an unsafe act – injured person or an unsafe condition – work place. l UNSAFE ACTS/CONDITIONS - caused by careless persons or poorly designed or improperly maintained equipment. l FAULT OF PERSONS - created by social environment or acquired by ancestry. l SOCIAL ENVIRONMENT/ANCESTRY - where and how a person was raised and educated.

7. Protect the Force Through Risk Management AC6 Heinrich’s Theory Corrective Action Sequence (The three “E”s) Engineering Education Enforcement

8. Protect the Force Through Risk Management AC7 Modern Causation Model OPERATING ERROR RESULT: -No damage or injury -Many fatalities -Major damage MISHAP (POSSIBLE)

9. Protect the Force Through Risk Management AC8 l How accidents are caused & how to correct those causes. l 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. Modern Causation

10. Protect the Force Through Risk Management AC9 Operating Errors:  Being in an unsafe position  Stacking supplies in unstable stacks  Poor housekeeping  Removing a guard Examples

11. Protect the Force Through Risk Management AC10 Revolutionized accident prevention A weakness in the design or operation of a system or program Systems Defect

12. Protect the Force Through Risk Management AC11 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

13. Protect the Force Through Risk Management AC12 Modern Causation Model OPERATING ERRORS RESULT: -No damage or injury -Many fatalities -Major damage MISHAP (POSSIBLE) SYSTEM DEFECTS Operating Errors occur because people make mistakes, but more importantly, they occur because of SYSTEM DEFECTS

14. Protect the Force Through Risk Management AC13 System defects occur because of Managers design the Systems Modern Causation Model OPERATING ERRORS RESULT: -No damage or injury -Many fatalities -Major damage MISHAP (POSSIBLE) SYSTEM DEFECTS COMMAND ERROR MANAGEMENT / COMMAND ERROR

15. Protect the Force Through Risk Management AC14 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 Safety Program Defect

16. Protect the Force Through Risk Management AC15 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

17. Protect the Force Through Risk Management AC16 Modern Causation Model SAFETY MANAGEMENT ERROR SAFETY PROGRAM DEFECT COMMAND ERROR SYSTEM DEFECT OPERATING ERROR MISHAP RESULTS

18. Protect the Force Through Risk Management AC17 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 Near-Miss Relationship 1 SERIOUS MINOR CLOSE CALL 29 300 1 SERIOUS MINOR CLOSE CALL 59 600

19. Protect the Force Through Risk Management AC18 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 Seven Avenues

20. Protect the Force Through Risk Management AC19 Seven Avenues Potential countermeasures for each modern causation approach include: SAFETY MANAGEMENT ERROR TRAINING EDUCATION MOTIVATION TASK DESIGN 1 23 4 5 6 7

21. Protect the Force Through Risk Management AC20 Seven Avenues Potential countermeasures for each modern causation approach include: SAFETY PROGRAM DEFECT REVISE INFORMATION COLLECTION ANALYSIS IMPLEMENTATION 2 3 4 5 6 7 1

22. Protect the Force Through Risk Management AC21 Seven Avenues Potential countermeasures for each modern causation approach include: COMMAND ERROR TRAINING EDUCATION MOTIVATION TASK DESIGN 3 4 5 6 7 12

23. Protect the Force Through Risk Management AC22 Seven Avenues Potential countermeasures for each modern causation approach include: SYSTEM DEFECT DESIGN REVISION VIA-- - SOP - REGULATIONS - POLICY LETTERS - STATEMENTS 4 5 6 7 12 3

24. Protect the Force Through Risk Management AC23 Seven Avenues Potential countermeasures for each modern causation approach include: OPERATING ERROR ENGINEERING TRAINING MOTIVATION 5 6 7 12 3 4

25. Protect the Force Through Risk Management AC24 Seven Avenues Potential countermeasures for each modern causation approach include: MISHAP PROTECTIVE EQUIPMENT BARRIERS SEPARATION 6 7 12 3 4 5

26. Protect the Force Through Risk Management AC25 Seven Avenues Potential countermeasures for each modern causation approach include: RESULT CONTAINMENT FIREFIGHTING RESCUE EVACUATION FIRST AID 7 12 3 4 5 6

27. Protect the Force Through Risk Management AC26 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 Army Systems Model

28. Protect the Force Through Risk Management AC27 TASK Army Systems Model Communication Control Arrangement Demands on soldiers Time aspects

29. Protect the Force Through Risk Management AC28 PERSON Army Systems Model Selection Mentally Physically Emotionally Qualified Motivation Positive Negative Retention

30. Protect the Force Through Risk Management AC29 Army Systems Model TRAINING Types Initial Update Remedial Targets Operator Supervisor Management Considerations Quality/Quantity

31. Protect the Force Through Risk Management AC30 Army Systems Model ENVIRONMENT Noise Weather Facilities Lighting Ventilation

32. Protect the Force Through Risk Management AC31 Army Systems Model MATERIEL Supplies Equipment Machine Design Maintenance

33. Protect the Force Through Risk Management Army Systems Model SAFETY MANAGEMENT ERROR SAFETY PROGRAM DEFECT RESULTMISHAP OPERATING ERROR SYSTEM DEFECT COMMAND ERROR Army Systems Model Task Training Environment Materiel Person

34. Protect the Force Through Risk Management AC33

35. Protect the Force Through Risk Management AC34