Download presentation
Presentation is loading. Please wait.
1
11/13/2018
2
11/13/2018 ACCIDENT CAUSATION
3
11/13/2018 Early Man
4
Factory managers reasoned that workers were hurt because —
11/13/2018 Industrial Revolution Factory managers reasoned that workers were hurt because — Number is Up Carelessness People Error ACCIDENT Cost of doing Business Act of God PEOPLE PROBLEM
5
Domino Theory “Industrial Accident Prevention”
11/13/2018 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 MISTAKES OF PEOPLE
6
Heinrich’s Theorems INJURY - caused by accidents.
11/13/2018 Heinrich’s 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.
7
Corrective Action Sequence (The three “E”s)
11/13/2018 Heinrich’s Theory Corrective Action Sequence (The three “E”s) Engineering Education Enforcement
8
Modern Causation Model
11/13/2018 Modern Causation Model RESULT: No damage or injury Many fatalities Major damage OPERATINGERROR MISHAP (POSSIBLE)
9
11/13/2018 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.
10
Examples Operating Errors: Being in an unsafe position
11/13/2018 Examples Operating Errors: Being in an unsafe position Stacking supplies in unstable stacks Poor housekeeping Removing a guard
11
Systems Defect Revolutionized accident prevention
11/13/2018 Systems Defect Revolutionized accident prevention A weakness in the design or operation of a system or program
12
Examples Systems defects include:
11/13/2018 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
Modern Causation Model
11/13/2018 Modern Causation Model RESULT: No damage or injury Many fatalities Major damage SYSTEM DEFECTS OPERATINGERRORS MISHAP (POSSIBLE) Operating Errors occur because people make mistakes, but more importantly, they occur because of SYSTEM DEFECTS
14
Modern Causation Model
11/13/2018 Modern Causation Model Managers design the Systems COMMAND ERROR RESULT: No damage or injury Many fatalities Major damage SYSTEM DEFECTS OPERATINGERRORS MISHAP (POSSIBLE) System defects occur because of MANAGEMENT / COMMAND ERROR
15
11/13/2018 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
16
Safety Management Error
11/13/2018 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
Modern Causation Model
11/13/2018 Modern Causation Model SAFETY MANAGEMENT ERROR SAFETY PROGRAM DEFECT COMMAND ERROR SYSTEM DEFECT OPERATING ERROR MISHAP RESULTS
18
Near-Miss Relationship
11/13/2018 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. RECENT STUDIES INITIAL STUDIES 1 SERIOUS MINOR CLOSE CALL 29 300 1 SERIOUS MINOR CLOSE CALL 59 600
19
11/13/2018 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
20
Potential countermeasures for each modern causation approach include:
11/13/2018 Seven Avenues Potential countermeasures for each modern causation approach include: SAFETY MANAGEMENT ERROR TRAINING EDUCATION MOTIVATION TASK DESIGN 1 2 3 4 5 6 7
21
Potential countermeasures for each modern causation approach include:
11/13/2018 Seven Avenues Potential countermeasures for each modern causation approach include: 2 SAFETY PROGRAM DEFECT 1 3 4 5 6 7 REVISE INFORMATION COLLECTION ANALYSIS IMPLEMENTATION
22
Potential countermeasures for each modern causation approach include:
11/13/2018 Seven Avenues Potential countermeasures for each modern causation approach include: 3 1 2 COMMAND ERROR 4 5 6 7 TRAINING EDUCATION MOTIVATION TASK DESIGN
23
Potential countermeasures for each modern causation approach include:
11/13/2018 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
24
Potential countermeasures for each modern causation approach include:
11/13/2018 Seven Avenues Potential countermeasures for each modern causation approach include: OPERATING ERROR ENGINEERING TRAINING MOTIVATION 5 1 2 3 4 6 7
25
Potential countermeasures for each modern causation approach include:
11/13/2018 Seven Avenues Potential countermeasures for each modern causation approach include: MISHAP PROTECTIVE EQUIPMENT BARRIERS SEPARATION 6 1 2 3 4 5 7
26
Potential countermeasures for each modern causation approach include:
11/13/2018 Seven Avenues Potential countermeasures for each modern causation approach include: 7 RESULT 1 2 3 4 5 6 CONTAINMENT FIREFIGHTING RESCUE EVACUATION FIRST AID
27
11/13/2018 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
28
Army Systems Model TASK Communication Control Arrangement
11/13/2018 Army Systems Model TASK Communication Control Arrangement Demands on soldiers Time aspects
29
Army Systems Model PERSON Selection Mentally Physically Emotionally
11/13/2018 Army Systems Model PERSON Selection Mentally Physically Emotionally Qualified Motivation Positive Negative Retention
30
Army Systems Model TRAINING Targets Types Considerations Initial
11/13/2018 Army Systems Model TRAINING Types Initial Update Remedial Targets Operator Supervisor Management Considerations Quality/Quantity
31
Army Systems Model ENVIRONMENT Noise Weather Facilities Lighting
11/13/2018 Army Systems Model ENVIRONMENT Noise Weather Facilities Lighting Ventilation
32
Army Systems Model MATERIEL Supplies Equipment Machine Design
11/13/2018 Army Systems Model MATERIEL Supplies Equipment Machine Design Maintenance
33
Army Systems Model SAFETY MANAGEMENT ERROR RESULT Army Systems Model
11/13/2018 Army Systems Model SAFETY MANAGEMENT ERROR RESULT Army Systems Model Task Training Environment Materiel Person SAFETY PROGRAM DEFECT MISHAP COMMAND ERROR OPERATING ERROR SYSTEM DEFECT
34
ARE THERE ANY QUESTIONS?
11/13/2018 ARE THERE ANY QUESTIONS?
Similar presentations
