Faculty of Chemical

Engineering
Universiti Teknologi
MARA

Process Safety - CPE615

THEORIES OF ACCIDENT
CAUSATION

QUIZ
List four theories of accident
Explain the term unsafe act
Give example of unsafe condition
Define overburden
Differentiate the term incident and accident

Process Safety - CPE615

INCIDENT VERSUS ACCIDENT

all undesired circumstances that
have the potential to cause accidents.
Accident: a sequence of events that produce
unintended injury, damage to property or the
environment, production losses, or increased
liabilities.
Accident refers to the event, not the results
of the event.

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Incident:

major accident defined as one having the

potential to kill 3 or more people or damage a
specific area of the environment or cause
property damage and loss in excess of a
particular sum.

minor accident might arise when the

release of a substance can cause illhealth/injury

NEAR MISS..
unplanned event that
did not result in injury,
illness, or damage but
had the potential to do so.
another term for this
event: close call

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an

ACCIDENT PYRAMIDS
- ACCIDENT RATIOS

Major
Injury

Major
Accident

10

29

Minor
Accident

300

Property Damage
Accidents

Minor
Injury
Incidents
(near miss)

H.W. Heinrich (1931)

30

600

Near miss

Frank E. Bird Jr
(1969)

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KEY QUESTIONS
do accidents occur?
How do accidents occur?
What must we do to keep them
from happening?

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Why

WHY DO ACCIDENTS OCCUR?

We

To

make a living
To provide society with desirable products

As

long as we choose to handle them, a

potential for loss events exist.

Things can be done to reduce their

likelihood and severity to negligible
or tolerable levels.

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choose to handle dangerous processes,

materials, energies

HOW DO ACCIDENTS OCCUR?

There

Domino theory
Human factors theory
Accident/incident theory
Sociotechnical system framework

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are several theories that

attempt to explain the occurrence
of accidents.
Most widely used theories of
accident causation:

DOMINO THEORY
Herbert

88% of industrial accidents are caused

by unsafe acts committed by workers

10% of industrial
accidents are caused by
unsafe conditions

2% of industrial
accidents are
unavoidable.

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W. Heinrich, an early pioneer of

accident prevention and industrial safety.
He studied 75,000 reports of accidents for
insurance claims and concluded:

HEINRICHS AXIOM OF INDUSTRIAL

SAFETY
result from a complete series of
factors, one of which is the accident itself
An accident can occur as a result of unsafe
act and/or unsafe conditions
Most accidents are the result of unsafe
behaviour by people
An unsafe act or an unsafe conditions does
not immediately result in an accident/injury;

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Injuries

HEINRICHS AXIOM OF INDUSTRIAL

SAFETY
reasons why people commit unsafe acts
can serve as helpful guides in selecting
corrective actions.
The severity of an accident is largely fortuitous
and the factors that cause it are largely
preventable.
The prevention techniques are analogous with
the best quality and productivity techniques.

Process Safety - CPE615

The

HEINRICHS AXIOM OF INDUSTRIAL

SAFETY
should assume responsibility
for safety because it is in the best position to
get results.
The supervisor is the key person in the
prevention of industrial accidents.
In addition to the direct costs of an accident
(i.e. compensation, liability claims, medical
costs, and hospital expenses) there are also
hidden or indirect costs.

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Management

5 FACTORS IN THE SEQUENCE OF

EVENTS LEADING UP TO AN
ACCIDENT
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Social
Environment
and Ancestry

Fault of
Person
(Carelessness)

Unsafe Act
or
Condition

Accident

Injury

5 FACTORS IN THE SEQUENCE OF

EVENTS LEADING UP TO AN
ACCIDENT

Negative character traits that might lead people

to behave in an unsafe manner can be inherited
or acquired as a result of the social environment.

Fault

and social environment

of a person

Negative character traits, whether inherited

or acquired, are why people behave in unsafe
manner and why hazardous conditions exist.

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Ancestry

5 FACTORS IN THE SEQUENCE OF

EVENTS LEADING UP TO AN
ACCIDENT

act/Unsafe conditions

Unsafe acts committed by people

Unsafe conditions due to the presence of
mechanical/physical hazards

Accidents

Typically, accidents that result in injury are caused

by falls and the impact of moving objects

Injury

Typical

injuries resulting from accidents include

laceration and fractures

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Unsafe

Example of unsafe act:

Operating without authority

Failure to warn or secure
Operating at improper speed
Making safety devices inoperable
Using defective equipment
Using equipment improperly
Failure to use PPE
Improper loading, placement
Servicing equipment in motion

Example of unsafe condition:

Inadequate
Defective

guards or protection

tools, equipment

Congestion,

bad housekeeping

Inadequate

warning system

Fire

and explosion hazards

Hazardous
Excessive

atmospheric condition

noise

Inadequate

illumination or ventilation

IDENTIFY UNSAFE ACT AND UNSAFE

CONDITION OF THIS SCENARIO AT A
FACTORY.
DIFFERENTIATE UNSAFE ACT AND UNSAFE
CONDITION BY LISTING THE NUMBER

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SCENARIO AT A FACTORY.

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HEINRICHS THEORY HAS TWO

CENTRAL POINTS:

are caused by the action of

preceding factors

Removal of the central factor (unsafe

acts/hazardous conditions) negates the
action of the preceding factors and, in so
doing, prevents accidents and injuries.

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Injuries

REMOVAL OF UNSAFE ACTS/UNSAFE

CONDITIONS PREVENTS THE
ACCIDENT

Accident
Unsafe act/unsafe condition
Fault of a person
Ancestry and social environment

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Injury

HUMAN FACTORS THEORY

Overload
Inappropriate
activities

Inappropriate
response

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Attributes accidents to a chain of events

that were ultimately the result of human
error.

OVERLOAD
imbalance between a persons capacity at
any given time and the load that a person is
carrying in a given state.

A persons capacity is
the product of such
factors as his/her
ability, training, state
of mind, fatigue,
stress, and physical
conditions.

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An

OVERLOAD
Added

Environmental factors
(noise, distractions, etc.);
Situational factors (level
of risks, unclear
instructions, etc.); and
Internal factors
(personal problems,
emotional stress, worry,
etc.)

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burden
resulting from

INAPPROPRIATE ACTIVITIES

of
inappropriate activities
include:

A person undertaking a task he

or she doesnt know how to do
(performing tasks without
requisite training)
A person misjudging the degree
of risk involved in a given task
and proceeding based on that
misjudgment.

Process Safety - CPE615

Examples

INAPPROPRIATE RESPONSE
a person responds in a given situation
can cause or prevent an accident.
Inappropriate response include:

A person detects a hazardous condition but does

nothing to correct it;
A person removes a safeguard from a machine in
an effort to increase output; or
A person disregards an established safety
procedure

Such

responses can lead to accidents.

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How

ACCIDENT/INCIDENT THEORY
the extension of the human factors theory
which was developed by Dan Petersen.
Introduced such new elements as ergonomic
traps, the decision to err, and system failure.
In this model, overload, ergonomic traps and
decision to err lead to human error.
The system failure is an important
contribution of Petersens theory.

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This

SOME WAYS THAT A SYSTEM FAILS PETERSEN

Management

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does not establish a

comprehensive safety policy.
Responsibility and authority with regard to
safety are not clearly defined.
Safety procedures such as measurement,
inspection, correction and investigation are
ignored or given insufficient attention.
Employees do not receive proper orientation.
Employees are not given sufficient safety
training.

Petersens Accident/Incident
Theory
Overload

Decisions to
err

Incompatible
workstation
Incompatible
expectation

Misjudgment
of the risk
Unconscious
desire to err

Human
Error
System failure
Policy
Responsibility
Training
Inspection
Corrections
Standards

Accident
Injury/ Damage

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Pressure
Fatigue
Motivation
Drugs
Alcohol
Worry

Ergonomics
Traps

THE SOCIOTECHNICAL FRAMEWORK

fault in an incident scenario will have
been affected by root causes.
Failures in large industrial system cannot be
considered solely in technical terms.
The sociotechnical system approach
emphasises the individual, organisational,
management and technical aspects which
affect a systems performance.

Process Safety - CPE615

Every

THE SOCIOTECHNICAL SYSTEM FRAMEWORK

System climate
Communication &
information system

Working environment

External
system
Organization
management
Management
control
Operator
performance

Procedures &
Practices
Site & plant
facilities
Engineering
integrity

 External

systems are influences outside the

boundary of the system which affect it but are
not significantly affected by the system itself.

System

climate includes influences such as

business factors corporate culture, safety
culture and technical know-how which exist
within the environment of the company.

ORGANISATION AND
MANAGEMENT

provides the scope for decision-making and

problem-solving within a company.
It

is the structure within which processes and

roles are defined and allocated to meet the
functional requirement of the plant.
This includes general conditions of work,
relationships formally defined by
organisational charts and job description.
Resources provision should be sufficient and
adequately allocated to the various functions
such as finance, expertise, information,
equipment and emergency needs.

Site and plant facilities address

the plant design and its realisation,
the layout of the site,
safety issues of current engineering projects and
consideration of the storage and transport of
materials.
Engineering integrity refers to
the reliability and availability of the plant - that
is, the hardware, machinery and its associated
control systems
which need to be assured beginning from the
design of the plant and continue through to
fabrication, installation, operation and
maintenance.

MANAGEMENT CONTROL
refers

more specifically to the management of

safety for this particular study.
It

includes factors such as the setting of standards,

performance indicators, priorities and targets,
maintaining and-improving those standard
Decision-making functions, allocations of resources
are examples of activities in this subsystem.
Supervisory is a key factor.

COMMUNICATION AND
INFORMATION
refers

to the dissemination and processing of

information vital to the safe functioning of
the system.
These

include the provision of operating

procedures, plant logs, permit-to-work systems and
also emergency response information.
Toxicity data, material safety data sheets (MSDS)
and operating parameters are elements to be noted
when reviewing this subsystem.
Communication systems must be effective.

PROCEDURES AND PRACTICES

provide clear instructions for conducting

activities in a safe manner in the-to-day running
of the operations.
Rigorous

and accurate procedures are the basis for

safe and reliable operation.
Proper dissemination and training in use is
important in promoting good working practices.

WORKING ENVIRONMENT

refers to the workplace and the conditions within

it.
How

the operators work and go about their task are

considered.
It is helpful to consider features such as welfare, the
safety culture prevailing and the availability of
immediate supervision and support.

OPERATOR PERFORMANCE

refers to the activities in which shop-floor

employees are involved.
These

are the individuals who have direct interaction

with the plant - operating staff, supervisors, fitters
and maintenance staff.
It encompasses all aspects which directly affects staff
performance including level of training and skills,
workplace design, psychological and physiological
effects.

EXERCISE
Incident VS Accident
Major accident VS Minor Accidents
Accident VS Near miss
List the theories of accident causation
List the 5 factors in the sequence of events
leading up to an accident
Immediate cause VS Root cause

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Human
Factors
Theory

Inappropriate
Response

Inappropriate
Activities

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Overload

Human
Factors
Theory

Environmental
factors
Internal Factors
Situational
Factors

Inappropriate
Response

Inappropriate
Activities

Detecting hazard
but not correcting
it
Removing
safeguards from
machines &
equipment
Ignoring safety

Performing task
without the requisite
training
Misjudging the
degree of risk
involved with a given
tasks

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Overload

CASE STUDY
Mr

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harith is an apprentice machinist at ABC

plant. One day, his supervisor took a vacation for
one week. The management assigned him to
replace his supervisor. He is then given a task to
handle the machine for the production of the day.
The management reminded him to handle the
machine in an appropriate manner as this
machine has constant reported failure. In a hurry
to be on schedule, and fearing the machine would
break down again, he ran his hand into the cutter
on his milling machine. After the accident, he
realized that he had forgotten to read the safety
procedure available next to the machine.
Discuss this accident scenario based on the theory
of accident causation

Process Safety - CPE615

Purpose an accident scenario which relates the

human factors theory of accident causation