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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).
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.
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
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.
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)
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
Injury PostInjury
Table 3. Haddon Matrix.
Slippery ladder
Concussion
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.
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.
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.
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.
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.