Accident Causation and Investigation Techniques
Investigation Procedure
1. Secure the scene of the accident 2. Provide care to the injured 3. Isolate the scene of the accident 4. Lead investigator selects team, assigning specific tasks to each member 5. Briefing to investigative team 6. Inspect the accident site 7. Interview victims and eyewitnesses 8. Determine most likely causes 9. Implement corrective actions
Multilinear events sequencing method
An integrated body of concepts and procedures for investigating and analyzing a wide range of desired and undesired processes before or after they happen
Safety management error, safety program defect, management/command error, system defect, operating error, mishap, result
Avenues for initiating countermeasures
Safety program defect countermeasures
Revise information collection, analysis, implementation
Ishikawa
Root cause analysis method that relies upon creation of a graphical "fishbone" diagram showing the influencing factors in the causation of an incident
System defect countermeasures
SOP's, regulations, policy letters, statements
Energy Release Theory
Theory that portrays accidents in terms of energy and transference where large amounts of energy can disrupt people and the environment and cause injuries.
combination theory
the actual cause of an accident may be explained by combining many models
Petersen's Accident/Incident Theory
theory that says that their are three ways accidents happen, either by overload, ergonomic traps, or decision to err
Operating errors countermeasures
training and motivation
Mishap countermeasures
PPE, barriers, separation
Gross Hazard Analysis
Performed to get a rough assessment of the risks involved in performing a task. Typically takes the form of a diagram or table
Systems Theory
Theory that explains that accidents are related to the relationship between man, machines, and the environment
2, 10, 88
% of unavoidable accidents, % of unsafe conditions, % of unsafe acts
Job Safety Analysis
A process through which all the various steps in a job are identified and listed in order.
Result countermeasures
Containment, firefighting, rescue, evacuation, first aid
Heinrich's Three E's
Engineering, Education, and Enforcement
Near-miss relationship
For every disabling injury, there are 29 minor injuries and 300 close calls
Epidemiological Theory
Studies the relationship between environmental factors and disease. 1. Predisposition Characteristics - Tendencies may predispose worker to certain actions 2. Situational Characteristics - Peer pressure, poor attitude, risk taking
Modern Causation Model
Theory that describes injuries as results and accidents as mishaps.
Safety management error and Command error defect countermeasures
Training, education, motivation task design
operating error
Unsafe position, unstable stacks, poor housekeeping, removing a guard
Failure modes and effects analysis
a procedure for identifying and correcting potential safety problems inherent to product or process designs
Fault Tree Analysis
a visual method for analyzing the interrelationships among failures
Heinrich Domino Theory
an accident is one factor in a sequence that may lead to an injury. An accident occurs only as a result of a personal or mechanical hazard. Personal and mechanical hazards exist only through the fault of careless persons or poorly designed or improperly maintained equipment. Faults of persons are inherited or acquired as a result of their social environment or acquired by ancestry. The environment is where and how a person was raised and educated.
Human Factors Theory
attributes accidents to a chain of events ultimately caused by human error
behavior-based safety
identifying the worker behaviors that contribute to accidents and then training workers to avoid these behaviors
system defects
improper assignment of responsibility, climate of motivation, training, education, equipment, supplies, allocation of funds
safety program defect
ineffective information collection, weak causation analysis, poor countermeasures, inadequate implementation and controls