Session No.

534

Using Accident Theories to Prevent Accidents

Jeffrey S. Oakley, Ph.D., CSP Safety Engineer The Boeing Company NASA Systems Houston, Texas

Introduction
Why should you wait until there is an accident at your workplace before you perform safety measures? Why should you wait until there is an accident to use the accident theories? Accident theories have been used for accident investigation and causal analysis for many years. It is time to start using these techniques in a proactive approach. This paper will teach you how to use these accident theories and analytical techniques used in accident investigation as proactive safety techniques that you can use to identify, analyze, and prevent hazards from becoming accidents. This paper will discuss accident theories, accident investigation techniques, system safety techniques, and other techniques that can be used in a proactive manner to prevent accidents from occurring in the first place. These techniques will be analyzed from an accident theory approach. There are many different types of accident theories that contradict each other so many different types of techniques and theories will be discussed. This paper will address the one question safety engineers have pondered for centuries. How do we prevent accidents? -- By first taking a look at how accidents occur. Accidents do not just happen--they are caused and the key is to find the causes and control them before there is an accident. This paper will look at many of the available accident theories and analyze how and why accident occur and discuss how to use them as proactive tools to prevent accidents. The purpose is to help use these techniques in the workplace to prevent future accidents by analyzing what happened.

What Is An Accident?
While many books will agree that an accident is an undesired event, the best definition that fits with the accident theories and analytical approach is that occurrence in a sequence of events that produces unintended injury, death or property damage (National Safety Council viii). Accidents are sequences of events. There are normal (positive) sequences where there is no accident, and then accident sequences also called negative sequences. An accident is a result of a negative sequence of events. Figure 1 displays a simple way to look at accidents and the facts or events that occurred.

FACT

FACT

FACT

ACCIDENT

FACT

TIME

Figure 1. The facts and events that lead to an accident (Oakley 66).

Analytical Approach to Accidents

The analytical approach to investigating accidents is used to find out what happened and how to prevent future accidents. This is a very intuitive and iterative process to use techniques that develop scenarios and determines what happened. The purpose is to use techniques and methodologies that help to determine the accident sequence and then prevent that sequence by corrective actions or controls. In the analytical approach as illustrated in Figure 1, the purpose is to use the techniques and methodologies to analyze the knowledge and facts to develop results or recommendations and corrective actions to prevent accidents. An analytical approach will establish consistency and validity to the proactive process.

Types of Accidents
There are many types of accidents and even OSHA categorizes them based on severity. While this is the regulatory process, the type of accident makes no difference. First aid injuries or fatalities and catastrophes are basically all the same. The theories apply to both the small accident and the large accident and even near misses. There is a sequence of events for all and while some are more complicated than others, they are basically the same. Many of these accidents are near misses because of luck more than safety controls. No matter what size of the accident (even near misses), they all have causal factors that caused the accident. They key to proactive safety is to identify the hazards and correct them before the accident.

How Accidents Occur?

Accidents are much more than the old clichs you were at the wrong place at the wrong time, you were unlucky, Boy you were due for an accident. Accidents can get anybody at anytime, however if one knows how they occur then there are steps to avoid them. Many employees put up a strong faade It wont happen to me, I dont need to work safe or wear this personal protective equipment. This carelessness and lack of respect to safety is usually what starts an accident sequence. There are many accident models. If you understand how they occur, then you are better able to prevent them from happening. These come in the form of medical theories, domino theories, human factors (human error) theories, and theoretical models or science fiction butterfly effect theories to name a few types. Table 1 lists these basic models that make up most of the accident theories. The medical theories are best explained by the new television shows. Crime Scene Investigation (CSI), medical shows, and the law shows use forensics to determine the crime or accident by using medical knowledge to find the cause. Some of these shows even use numbers, vision, and even special powers to figure out these accidents.

1. 2. 3. 4.

Accident Models Medical Models Domino Models Human Factors/Human Error Theoretical Models (Sci Fi)

Table 1. Accident Models make up many types. Most safety engineers have used various domino theories to understand how accidents occur. They start with a sequence of events that lead to other sequence of events, which eventually lead to an accident. Just like a domino, if all fall down then it creates an accident. In order for this to occur, all dominoes must be a cause or a negative path. If any of these dominoes were held up then there would be no accident. There has been much debate about the human factors or human error theories. This model relates the human part of the equation. How much the human or error relates to how an accident occurs has been debated for years. While human behavior and actions are usually a factor in many accidents, its causal relationship has been decreased in the safety and accident prevention realm. The last type of model is the theoretical concept or science fiction style or butterfly effect phenomenon. How does a butterfly flapping its wings in France affect a person in the United States? While this is a unique concept, the key to workplace is every action and condition can affect people at the workplace. What the process operator at a chemical plant does can reflect on another employee. This is the model that we use to tell our employees that we all need to work safe, because our actions can impact our fellow employee.

Accident Theories
There are many theories about why and how accidents occur, and understanding them is important. These theories are continually challenged and revised, and some of the theories contradict each other (Oakley 15). There is no real right answer as to which one of the accident theories is correct; it all depends on the type of model that you use. Most of these depend on your personal philosophy or your companies philosophy. The theories that will be discussed are listed in Table 2. 1. 2. 3. 4. 5. 6. 7. 8. Accident Theories Accident Ratio Study Domino Theories Multiple Cause Theory Epidemiological Theory Haddon Matrix Technical/Engineering Theories Human Error/Human Factors Theories Sequence of Events

Table 2. Accident Theories.

Accident Ratio Study

While this is not necessarily an accident causation theory, it does develop a relationship between major injuries, minor injuries, property damage, and near misses (close calls). Many of these pyramid relationships have been developed with different numbers, but the same concept is represented. Figure 2 illustrates the accident ratio study and Bird and Germain sums up this concept as The 1-10-30-600 relationships in the ratio indicate quite clearly how foolish it is to direct our major effort at the relatively few events resulting in serious or disabling injury when there are so many significant opportunities that provide a much larger basis for more effective control of total losses (Bird and Germain 21). This ratio tries to get the safety engineer to use more proactive approaches from near misses, close calls, and hazards to prevent the accident.

1 Major Injury 10 Minor Injuries 30 Property Damage 600 Near Misses

Figure 2. Accident Ratio Study.

Domino Theory
There are many types of domino theories that have been developed over the years. The original was Heinrichs domino theory of accidents. Heinrichs version of the domino theory illustrates how an accident occurs by comparing the events leading up to it to a set of dominos. The first domino (the first event) sets the stage and starts the accident sequence. When it falls, it pushes the next, and that pushes the next, until the last domino, which represents the accident or injury, is toppled (Oakley 18). Figure 3 represents this domino theory. As a proactive approach, Heinrich showed that by removing one of the intervening dominos (a preventative action) the remaining ones would not fall, and there would be no injury (Ferry 127).

Figure 3. The Domino Theory starts with lack of control-basic causes-immediate causesincident-loss.

Another domino theory is the loss causation model, which starts with lack of control, basic causes, immediate causes, incident, and then loss. This model defines that the control of the situation, policy, supervision, or safety is lacking which started the domino and the negative sequence. A personal or job factor that influences the negative path then starts the accident sequence. The next step is waiting for the unsafe act or condition and then an incident (Bird and Germain 22). This is a widely used domino theory is a very good theory of how they occur. There has been much discussion lately about another important development from the domino theory and that is unsafe acts and unsafe conditions. These are usually the superficial causes of accidents. The main issue is to make sure that systemic causes and factors of accidents are developed and analyzed. A good example is when a construction worker steps into a hole. Many times in this analysis the cause is an unsafe act of the construction worker not paying attention, while a real issue is why the hole was not guarded. An even higher-level analysis could be supervision or budget issues.

Multiple Cause Theory

Accidents are rarely caused by one act or condition. They are the result of many acts, conditions, and causes (complex, simple, obvious, obscure, and systemic). The System Safety Development Center from the Department of Energy stated When considering why an accident or incident occurred, more than one root cause must be considered. Very seldom will just one root cause create a condition that results in an accident. In most cases it requires a chain of root causes that reaches from top management to the lowest level of the work process. Correcting the specific root causes generally will only correct the bottom-level conditions. Correcting the systemic root causes is more likely to correct all of the root causes in a particular chain that reaches from management to the bottom work processes. (SSDC ii). If safety engineers only analyze only acts and conditions they will miss many higher-level issues and this theory is based on Dan Petersons statement Today we know that behind every accident there lie many contributing factors, causes, and subcauses. The theory of multiple causation states that these factors combine together in random fashion, causing accidents. If this is true, our investigation of accidents ought to identify as many of these factors as possible certainly more than one act and/or condition. (Peterson 16).

Epidemiological Theory
Another useful theory is the Epidemiological Triangle, which consists of the host (the person who gets a disease), the agent that cause the disease (virus, bacteria, etc.), and the vehicle or environment that carries the disease (mosquito, tick, water sources, etc.). This concept can be applied to accidents when the host is the person injured, the agent is what did the injuring, and the vehicle is what conveyed the agent. This is a simple diagram of an accident at shown in Figure 4.

Host

Agent

Vehicle (Environment)

Figure 4. Epidemiological Triangle.

Haddon Matrix
The Haddon Matrix is a theory of the factors and phases of injury. Each accident has a preinjury, injury, and a post-injury phase. During these three phases there are three factors that influence the outcomes of the event. These events are the interactions between the human, equipment, and the environment in each phase of injury. A sample Haddon Matrix is included in Table 3.

HADDON MATRIX
FACTORS
Human Equipment
Oily boots

Environment
Rainy

Pre-Injury
PHAS ES

Time pressure to perform the job (rushing job)

Feet and hands slipping on ladder

Injury PostInjury
Table 3. Haddon Matrix.

Distance to ground (distance of fall) Ladder fell over on top of employee

Slippery ladder

Concussion

Emergency medical response late due to rain

Technical/Engineering Approach
Technical or engineering approaches to accident theories are very specific and discover lower level causes and system failures. They are excellent for discovering and investigating system or equipment failures, but too narrow in scope for most other types of accidents.

Human Error/Human Factors Theory

There are many different types of human factors or human error theories. The basis of these theories is to identify the human/machine/environment interface. The key is to determine if the interface or interaction had an effect on the accident. The steps are to analyze how the human interacted with the machine, equipment, environment, etc. The key is to focus on the work environment that produces the bad behaviors and try to eliminate the behavior instead of focusing on the human error (Oakley 36). One of the main parts to human error theory is to determine the

type of error. Error of omission is when one forgets to do something or misses a step, which is usually caused by a distraction or diversion. Errors of commission is when someone performs incorrectly or does something wrong, which is usually a lack of training.

Sequence of Events
The last theory is not so much of a theory, as a way to visualize an accident. All accidents are a sequence of events. This philosophy lends itself to using many of the other theories, such as multiple causation and the domino theory. The concept of this is to develop scenarios and sequence of events to develop accidents, and then try to use controls to prevent them from occurring.

Why Proactive Safety?

The key concept is to prevent accidents. No one wants to get hurt, but actions and conditions will dictate an accident. All accidents are caused and there are many consequences of accidents. The health and safety of personnel is the utmost priority, but other issues include functional capability of the plant after loss, public image and reputation, financial well-being (loss of sales), and also civil or criminal legal action. Proactive safety is identifying hazards (both facility hazards and hazardous actions by people). These hazards are the start of the accident sequence. Each hazard must be identified so a thorough analysis can be performed to find the ways an accident can occur. The last step is to control the hazards as shown in table 4. Proactive safety is analyzing systems and tasks to work safely and developing a safety philosophy to work safe on every task. This philosophy will keep systemic problems from becoming an accident sequence. Safety Motto IDENTIFY HAZARDS ANALYZE HAZARDS CONTROL HAZARDS Table 4. The steps for Proactive Safety.

Systems Safety Approach

The key to a systems safety or task safety approach is to analytically and methodically identify, analyze, and control hazards before an accident occurs. The concept of conducting analyses is to break down the system versus the job or task. Analyze the systems such as the piece of equipment and look for hazards. Then break down the tasks, what is the process for obtaining the wood, loading it into the machine, etc. Obtain all of the hazards for this task also. The next step is to ensure the hazards versus failures. Many of the systems safety techniques find failures, however to prevent accidents you must look for hazards.

Proactive Safety Techniques Using Accident Theories

The key to all accidents is to uncover and analyze the accident sequence, determine the causal factors, and find corrective actions that will prevent future accidents. After the hazards are identified and analyzed, causal factors are developed. Using these accident theories, the causal factors or what would have prevented the accident are used to develop the proper controls or corrective actions. The theories should be used to validate and find systemic problems at all levels. Management issues, worker issues, engineering issues (design), as well as policy issues need to be analyzed. All levels need to be looked at to provide corrective actions and accountability to prevent accidents. Telling a worker to work safer will only prevent that worker from having a future accident. If the control is a policy issue or a design issue, then the corrective action needs to be addressed at that level to fix future accidents. Proactive safety is a chance to look at the failures in the safety program and fix them. (It is not the time to place blame or look at human error. This is the time to look at what caused the human error.) The next step to prevent accidents is to implement the corrective actions. All corrective actions need to be tracked and a strict timetable established. If corrective actions are assigned to a department or someone is accountable for the corrective action, then usually they will be fixed in a more timely manner. All corrective actions or recommendations must be communicated clearly and objectively. The last step is to conduct a follow up and make sure the corrective actions are in place or working correctly to prevent accidents.

Compliance/Regulations
One of the best ways to use the theories of accidents is to use the standards/regulations to find hazardous situations. While standards are the minimal compliance, it is a great starting point. When performing a walkaround look for potential accident sequences or use the OSHA categories of accidents as listed in Table 5. These are the categories that would be marked for an OSHA recordable, so if you alleviate these form occurring, then you dust stopped the domino or sequence of events of an accident. OSHA Categories of Accidents Struck By Caught In Struck Against Fall, Same Level Caught Between Fall to Below Contact With Overexertion Contact By Exposure Contact On Table 5. OSHA Categories of Accidents.

Job Safety Analysis

Everyone has probably performed the basic job safety analysis of listing the steps to a job, documenting the hazards, and developing controls. A job safety analysis is an excellent proactive safety approach. When conducting a job safety analysis, look at the potential dominos and sequence of events for an accident. Look for negative paths and use the OSHA categories to structure your hazards. Also use the unsafe acts/unsafe conditions to determine where lack of control situations can occur.

While identifying the hazards is the hardest step of the job safety analysis, the most important step is developing solutions to prevent the accident. The hazard control precedence was developed to try to prevent the accident in the best possible way to ensure that the control is fixed. The first step is to try to design out or get rid of the hazard, if that cannot be accomplished, then to try to substitute for a less hazardous task or equipment. The next step is to try to use guards and safety devices to reduce the hazard. The next step is to use administrative controls and procedures to control the hazard. The last step is to use personal protective equipment to guard the person from the hazard. This is extremely important in that you want to try to control the hazard at the highest level (System Safety Society 1).

Barrier Analysis
This is a simple analysis that is very good at locating hazards and controlling them. A barrier analysis is fairly simple to perform keep the hazard from the target. This type of barrier analysis considers potential hazards, the potential targets, and assesses the adequacy of barriers or other safeguards that should prevent or mitigate an accident (Spear 27). This analysis is extremely useful because it produces a graphical chart. The outcome can graphically explain the accidents failures and also find the barriers that need to be corrected or added to prevent accidents. The approach to this technique is very simple and is listed in Table 6. There is a hazard and a target. The barriers try to keep the hazard from reaching the target. The first step is to identify the hazard and the target. The next step is to identify or brainstorm all of the barriers to get a comprehensive list and documented on a form as shown in Table 7. Performing a Barrier Analysis 1. Identify the hazard and the target 2. Identify (brainstorm) barriers and controls 3. Evaluate the intended function of the barrier Table 6. The steps needed to perform a barrier analysis. Barrier Barrier Analysis Form Purpose of Barrier

Table 7. The steps needed to perform a barrier analysis. The barrier analysis summary chart can be an excellent graphical chart that displays the failures of barriers for the accident in an easy to read graphical format. This chart can be generated easily from the worksheet and be very helpful in developing corrective actions to prevent future accidents. An example of a barrier analysis summary chart is illustrated in Figure 5.

Barrier Analysis Summary Chart HAZARD Fall

Plant Procedure BARRIERS Fall Protection Safety Training

TARGET

Worker

Figure 5. Barrier analysis summary chart is an excellent tool to show the barriers and what needs to be corrected to prevent an accident.

Summary
It is important to understand how and why accidents occur by looking at the many accident theories. The accident theories are a great tool to use, not only for accident investigations, but to try to prevent accidents from occurring. Proactive safety techniques are extremely useful in identifying, analyzing, and controlling accidents. Simple techniques can be used to prevent these accidents. It is important to understand the aspect of and impact of proactive safety and the true reasons these tools and techniques are applied, which is to prevent accidents.

Bibliography
Bird, F. and G. Germain. Practical Loss Control Leadership. Loganville, GA: International Loss Control Institute, 1985. Ferry, T. Elements of Accident Investigation. Springfield, IL: Charles C. Thomas, 1978. National Safety Council. Accident Prevention Manual for Business and Industry, 12th ed. Itasca, IL: National Safety Council, 2001. Oakley, J. Accident Investigation Techniques: Basic Theories, Analytical Methods, and Applications. Des Plaines, IL: ASSE, 2003. Oakley, J. and S. Smith. Ergonomic Assessment and Design: The Key to Back Injury Prevention. Professional Safety. Feb. 2000: 35-38.

Peterson, D. Techniques of Safety Management. New York: Mcgraw Hill Book Company, 1978. Spear, J. Incident Investigation: A Problem-Solving Process. Professional Safety. April 2002: 25-30. System Safety Development Center. MORT Based Root Cause Analysis. DOE SSDC-27, 1989. Systems Safety Society. Systems Safety Analysis Handbook, 2nd Ed. Systems Safety Society. 1997.