Accident Causation
Investigations
Incident Causation
Not Just for Fatalities
Objectives
• Familiarize with incident causation
• Apply root cause analysis
Heinrich Domino Theory
Management / Root Cause
• Management Structure objectives organization operations
Operational Error
Manager behavior/Supervisor behavior
Tactical Error unsafe acts unsafe conditions
LCU Theory
• Accident probability is situational • Overload taxes person’s capacity • Leads to accidents (or illness) • >300 → 79% in 2 yrs
• >200 → 51% in 2 yrs
• >150 → 37% in 2 yrs
#1
Death of Spouse
100
#2
Divorce
73
#3
Marital Separation 65
#4
Jail term
63
#5
Death of family
63
#6 personal injury
53
#12 Pregnancy
40
#30 Mortgage
31
#41 Vacation
13
#42 Christmas
12
Human Factors Models
Dr. Russell Ferrell
• 1. overload of motivational or arousal state • 2. incorrect response due to overload
• 3. didn’t know any better or took deliberate risk
• Human error—initiating incidents--accidents---outcomes
Hazards
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Impact Penetration Compression Chemical Heat Harmful dust Lighting Radiation Slick Surfaces Electrical
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Sources of Motion Sources of temperature change Source of chemical exposure Sources of Harmful dust Sources of Light/Radiation Sources of falling objects Sources of sharp edges Sources of spills/slip hazards General layout of workplace/station and location of workers
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• Sources of Noise
Case # 1
Logging
West Virginia
• August 13, 2003
• Operator was a sporadic employee, 46 years old
• Dozer owned by decedents brother, not company • Logging company of 3 peopleowner(feller), 1 laborer, 1 dozer operator;
Owner certified logger
• Cause of death- crush injuries
Model Application
• Unsafe Act (s)
• Job Factors/Unsafe Conditions
• Operational Errors (manager/supervisor)
• Management/Systems Factors
• Stresses?
• Overloaded capacity? Deliberate risk?
Official Citations
• The OSHA Logging
Incident Causation
Not Just for Fatalities
Objectives
• Familiarize with incident causation
• Apply root cause analysis
Heinrich Domino Theory
Management / Root Cause
• Management Structure objectives organization operations
Operational Error
Manager behavior/Supervisor behavior
Tactical Error unsafe acts unsafe conditions
LCU Theory
• Accident probability is situational • Overload taxes person’s capacity • Leads to accidents (or illness) • >300 → 79% in 2 yrs
• >200 → 51% in 2 yrs
• >150 → 37% in 2 yrs
#1
Death of Spouse
100
#2
Divorce
73
#3
Marital Separation 65
#4
Jail term
63
#5
Death of family
63
#6 personal injury
53
#12 Pregnancy
40
#30 Mortgage
31
#41 Vacation
13
#42 Christmas
12
Human Factors Models
Dr. Russell Ferrell
• 1. overload of motivational or arousal state • 2. incorrect response due to overload
• 3. didn’t know any better or took deliberate risk
• Human error—initiating incidents--accidents---outcomes
Hazards
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Impact Penetration Compression Chemical Heat Harmful dust Lighting Radiation Slick Surfaces Electrical
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Sources of Motion Sources of temperature change Source of chemical exposure Sources of Harmful dust Sources of Light/Radiation Sources of falling objects Sources of sharp edges Sources of spills/slip hazards General layout of workplace/station and location of workers
•
• Sources of Noise
Case # 1
Logging
West Virginia
• August 13, 2003
• Operator was a sporadic employee, 46 years old
• Dozer owned by decedents brother, not company • Logging company of 3 peopleowner(feller), 1 laborer, 1 dozer operator;
Owner certified logger
• Cause of death- crush injuries
Model Application
• Unsafe Act (s)
• Job Factors/Unsafe Conditions
• Operational Errors (manager/supervisor)
• Management/Systems Factors
• Stresses?
• Overloaded capacity? Deliberate risk?
Official Citations
• The OSHA Logging
Citations: • Furthermore, 1910.266 (d)(3)(ii) & (iii) requires the use of an available seat belt