1. Why Do We Have Accidents?
Accident Causation
Why Do We Have Accidents?
Updated 1 July 2014

2. Causation History Early man – Accidents were the result of Bad Spirits
Civilized man - Injured person was at fault due to stupidity

3. USASC conducted a study of cause factors based on class A-C accidents from FY99-FY01. The results indicate that, although the percentages differ, the top four causes of accidents in Aviation and Ground are the same: indiscipline, leadership, training and standards. These categories are explained in general terms below.
Indiscipline-- The soldier knew what to do, but chose an incorrect action because of habit, attitude, or mental lapse.
Leadership-- Someone in the chain of command failed to inform, motivate, plan, or correct the soldier’s action.
Training-- The soldier was not taught, or made to remember, the correct action.
Standard-- No one thought up, or wrote down, the correct action.

4. Causation History
Industrial revolution – carelessness caused accidents.
Natural side effect of production
Cost of doing business
Human nature – people will always be careless

5. Causation History The court system Public opinion
Upheld the view of individual responsibility
Injured worker had to sue
Employer had to be found completely to blame
Public opinion
Rose against rose against the "worker alone-is-to-blame" theory.
Courts became more responsive to workers' claims.
By 1908 State legislatures implemented an employer's liability law.

6. Causation History Employers take notice
Financial responsibility for an injured worker
More cost effective to prevent accidents.
Only theory remained personal carelessness
Safety program success was hit and miss

7. Industrial Revolution
“Acts of God”
Natural
Side Effect of
Production
ACCIDENTS
People Errors
Number Is
Up Approach
Carelessness
Employers Rationale for Accidents

8. Heinrich’s Theory Scientific Approach
Heinrich’s model to accident causation has been the basic approach in accident prevention and has been used mostly by safety societies and professional people since its publication in This was the first scientific approach.

9. Heinrich’s Accident Causation Model
Social
Environment
& Ancestry
Fault
of the
Person
Unsafe Act Or
Unsafe
Condition
Accident
Injury
Mistakes of People

10. Accident Causation 1932 - First Scientific Approach To
Accident Prevention – H.W. Heinrich
“Industrial Accident Prevention”
Heinrich began with the fact of injury and traced it back to its causes. An injury, he reasoned, was caused by an accident, and an accident was caused by either an unsafe act on the part of the injured person or an unsafe condition in the environment.
The next step back in Heinrich’s accident causation model again placed blame squarely on the individual and then, in the next step makes a vague reference to the person’s social environment and ancestry as the causation reason for his carelessness or fault.
This was a major breakthrough because it removed some of the blame from the individual worker. The worker might have been careless but it might have been caused because the machine was poorly designed or maintained, thus making it likely whoever worked with it would be injured.
Managers could see the rationale behind the theory. Since one of the remedies against accidents dealt with “things” instead of people, employers had something concrete to correct. Machines, business and factory layouts were looked at with a new eye and were found to be sadly lacking in safety features.
A big push began to engineer for safety. This engineering for safety has been very effective and still is a big area of responsibility under the Occupational Safety and Health Act.
However, engineering out unsafe conditions was only part of Mr. Heinrich’s corrective action sequence. The other three pillars included:
Instruction – Workers taught how to do their job safely
Persuasion and appeal – people were exhorted to behave safely
Discipline – Worker threatened with loss of money or job if performance did not improve
Social
Environment
And Ancestry
Fault of the
Person
(Carelessness)
Unsafe Act Or
Condition
Accident
Injury
Mistakes of People

11. Three “E’s” of Accident Prevention
Engineering
Education
Enforcement
From Heinrich’s theory came the three E’s as we know them today.

12. Beyond Engineering Instruction Persuasion Discipline
However, engineering out unsafe conditions was only part of Mr. Heinrich’s corrective action sequence. The other three pillars included:
Instruction – Workers taught how to do their job safely
Persuasion and appeal – people were exhorted to behave safely
Discipline – Worker threatened with loss of money or job if performance did not improve

13. Modern Causation Model
Parallels Heinrich’s theory
“Injury” becomes “Result”
Varies from no damage to very severe
“Accident” becomes “Mishap”
Injury not required
“Unsafe Act or Unsafe Condition” becomes “Operating Error”
Act and condition captured as error

14. Modern Causation Model
No damage
or injury
RESULTS
Major damage
Or fatalities
OPERATING
ERROR
MISHAP

15. Modern Causation Model
Disrupted
Operation
No damage
or injury
RESULTS
Major damage
Or fatalities
OPERATING
ERROR
MISHAP
RESULTS

16. Modern Causation Model
Disrupted
Operation
Event
No damage
or injury
RESULTS
Major damage
Or fatalities
OPERATING
ERROR
MISHAP
RESULTS

17. Modern Causation Model
Failure to properly
operate or maintain
facilities or equipment
Injury or
damage
Event
No damage
or injury
RESULTS
Major damage
Or fatalities
OPERATING
ERROR
MISHAP
RESULTS

18. Modern Causation Model
Single Most Important
Addition to New Model
System Defect
SYSTEM
DEFECT
No damage
or injury
RESULTS
Major damage
Or fatalities
Addition of system defects breaks away from Heinrich and adds concept that virtually revolutionizes accident prevention.
This key concept is the single most important concept yet developed in acident prevention theory, it changes what we seek to do and how we do it.
OPERATING
ERROR
MISHAP
RESULTS

19. System Defects
Weaknesses in the way the system is designed or operated
Improper assignment of responsibilities
Improper climate of motivation
Inadequate training and education
Inadequate or improper equipment or supplies
Poor personnel selection for job
Inadequate funding

20. Modern Causation Model
COMMAND/
MANAGEMENT
ERROR
SYSTEM
DEFECT
No damage
or injury
RESULTS
Major damage
Or fatalities
OPERATING
ERROR
MISHAP
RESULTS

21. Why does the manager fail to identify system defects or take action?
Management Error
Managers
Design systems
Create procedures
Enforce discipline
Provide training
Why does the manager fail to identify
system defects or take action?

22. Modern Causation Model
SAFETY
PROGRAM
DEFECT
COMMAND/
MANAGEMENT
ERROR
SYSTEM
DEFECT
No damage
or injury
RESULTS
Major damage
Or fatalities
OPERATING
ERROR
MISHAP
RESULTS

23. Safety Program Defect Ineffective information collection
Weak causation analysis
Poor countermeasures
Inadequate controls
Inadequate programs
Safety program defect
A defect in some aspect of the safety program that allows an avoidabl error to exist.
Ineffective information collection
Weak causation analysis
Poor countermeasures
Inadequate controls – They fail to implement the 5th step of the RM process.
Inadequate programs

24. Modern Causation Model
SAFETY
MANAGEMENT
ERROR
SAFETY
PROGRAM
DEFECT
COMMAND/
MANAGEMENT
ERROR
SYSTEM
DEFECT
No damage
or injury
RESULTS
Major damage
Or fatalities
OPERATING
ERROR
MISHAP
RESULTS

25. Safety Management Error
Knowledge
Motivation
Integration
Relevance
Safety management error
A weakness in the knowledge or motivation of the safety manager that permits a preventable defect in the safety program
Knowledge
Motivation
Integrated into command (primary staff)
Relevance – mission oriented and realistic

27. Accidents & Near Misses
Heinrich’s Initial
Research
Recent
Studies 1
Serious 1 29
Minor 59
Heinrich’s study in an industrial setting
Data displayed a near miss relationship between serious, minor and near miss mishaps. The initial study showed that for every serious injury there were 29 minor and 300 near miss incident.
Later studies discovered the same relationship but the data showed 59 minor injuries and 600 near misses for every 1 serious accident.
The bottom line is investigating minor and near miss incidents may provide the insight to create strategies to avoid the 1 serious accident.
Near Miss
300
600

28. 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

29. Modern Causation Model1 2 3 4
SAFETY
MANAGEMENT
ERROR
SAFETY
PROGRAM
DEFECT
COMMAND/
MANAGEMENT
ERROR
SYSTEM
DEFECT
No damage
or injury
RESULTS
Major damage
Or fatalities 5 6
OPERATING
ERROR
MISHAP
RESULTS 7

30. Potential Countermeasures
Seven Avenues
Potential Countermeasures
SAFETY
MANAGEMENT
ERROR
TRAINING
EDUCATION
MOTIVATION
TASK DESIGN 1 2 3 4 5 6 7

31. Potential Countermeasures
Seven Avenues
Potential Countermeasures 2
SAFETY
PROGRAM
DEFECT 1 3 4 5 6 7
REVISE INFORMATION
COLLECTION
ANALYSIS
IMPLEMENTATION

32. Potential Countermeasures
Seven Avenues
Potential Countermeasures 3
COMMAND/
MANAGEMENT
ERROR 1 2 4 5 6 7
TRAINING
EDUCATION
MOTIVATION
TASK DESIGN
DISCIPLINE
SUPPORT

33. Potential Countermeasures
Seven Avenues
Potential Countermeasures 4 1 2 3
SYSTEM
DEFECT 5 6 7
DESIGN REVISION VIA--
- SOP
- REGULATIONS
- POLICY LETTERS
- STATEMENTS

34. Potential Countermeasures
Seven Avenues
Potential Countermeasures
OPERATING
ERROR
ENGINEERING
SAFETY DEVICES
WARNING DEVICES
TRAINING
MOTIVATION 5 1 2 3 4 6 7

35. Potential Countermeasures
Seven Avenues
Potential Countermeasures
MISHAP
PROTECTIVE EQUIPMENT
BARRIERS
SEPARATION 6 1 2 3 4 5 7

36. Potential Countermeasures
Seven Avenues
Potential Countermeasures 7
RESULT 1 2 3 4 5 6
CONTAINMENT
FIREFIGHTING
RESCUE
EVACUATION
FIRST AID
Systems Model

37. The Army approach to accident causation allows us to:
Conclusion
The Army approach to accident causation allows us to:
Look beyond the individual
ID the systemic defect
Use the information to develop controls & prevent accidents

38. Army Systems Model SAFETY MANAGEMENT ERROR RESULT Army Systems Model
Task
Person
Training
Environment
Materiel
SAFETY
PROGRAM
DEFECT
MISHAP
COMMAND
ERROR
OPERATING
ERROR
SYSTEM
DEFECT

39. 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.

40. The elements of the Army Systems Model are:
Task
Person
Training
Environment
Materiel

41. Army Systems Model TASK Communication Control Arrangement
Demands on soldiers
Time aspects

42. Army Systems Model PERSON Selection Mentally Physically Emotionally
Qualified
Motivation
Positive
Negative
Retention

43. Army Systems Model TRAINING Targets Types Considerations Initial
Update
Remedial
Targets
Operator
Supervisor
Management
Considerations
Quality/Quantity

44. Army Systems Model ENVIRONMENT Noise Weather Facilities Lighting
Ventilation

45. Army Systems Model MATERIEL Supplies Equipment Machine Design
Maintenance

46. (System Inadequacies/Root Cause)
DA PAM
3 W’s Approach to Information Collection, Analysis and Recommendations
Why Did it
Happened ?
(System Inadequacies/Root Cause)
Leader
Training
STDS / Procedures
Support
Individual
What
Happened ?
(cause Factors)
Human Mistakes/Errors
Materiel Failure
Environmental Factors
What to do About it ?
(Recommendations)
Fixes
Remedial Measures
Countermeasures

47. RECENT STUDIES
SERIOUS 1
MINOR 59
NEAR MISS
600

48. How to analyze the Near Miss
Identify the systemic defect

49. Person Army System Model Task Training Environment Material SYSTEM
DEFECT

50. How to analyze the Near Miss
Identify the systemic defect
Identify cause factors:

51. (System Inadequacies/Root Cause)
Cause Factors
Why Did it
Happened ?
(System Inadequacies/Root Cause)
Leader
Training
STDS / Procedures
Support
Individual
What
Happened ?
(cause Factors)
Human Mistakes/Errors
Materiel Failure
Environmental Factors
What to do About it ?
(Recommendations)
Fixes
Remedial Measures
Countermeasures

52. (Cause Factors) Cause Factors What Happened ? Human Mistakes/Errors
Materiel Failure
Environmental Factors
Cause Factors

53. How to analyze the Near Miss
Identify the systemic defect
Identify cause factors:
Human, Materiel, Environmental
If human –
Identify the system inadequacies, the root cause
Leader, Training, Standards, Support, Individual

54. (System Inadequacies/Root Cause)
Why Did it
Happened ?
(System Inadequacies/Root Cause)
Leader
Training
STDS / Procedures
Support
Individual
What
Happened ?
(cause Factors)
Human Mistakes/Errors
Materiel Failure
Environmental Factors
What to do About it ?
(Recommendations)
Fixes
Remedial Measures
Countermeasures

55. (System Inadequacies/Root Cause)
Why Did it
Happened ?
(System Inadequacies/Root Cause)
Leader
Training
STDS / Procedures
Support
Individual
System Inadequacies

56. Near Miss - Summary Identify the systemic defect
Identify cause factors:
Human, Materiel, Environmental
If human –
Identify the system inadequacies and root cause
Leader, Training, Standards, Support, Individual

57. ARE THERE ANY QUESTIONS?