ASET INSTITUTE OF TECHNOLOGY

Unit II

Accident Causation Theories

Heinrich's Domino Theory:

According to Heinrich, an "accident" is one factor in a sequence that may lead
to an injury.

• The factors can be visualized as a series of dominoes standing on edge; when one
falls, the linkage required for a chain reaction is completed.

• Each of the factors is dependent on the preceding factor

1932 First Scientific Approach to Accident/Prevention - H.W. Heinrich

Heinrich’s Dominos – The Process

1. A personal injury (the final domino) occurs only as a result of an accident.

2. An accident occurs only as a result of a personal or mechanical hazard.
3. Personal and mechanical hazards exist only through the fault of careless
persons or poorly designed or improperly maintained equipment.
4. Faults of persons are inherited or acquired as a result of their social
environment or acquired by ancestry.
5. The environment is where and how a person was raised and educated.

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Heinrich’s Domino Theory – Critical Issues

 The factor preceding the accident (the unsafe act or the mechanical or physical
hazard) and it should receive the most attention.

 Heinrich felt that the person responsible at a company for loss control should
be interested in all five factors, but be concerned primarily with accidents and
the proximate causes of those accidents.
 Heinrich also emphasized that accidents, not injuries or property damage,
should be the point of attack.
An accident is any unplanned, uncontrolled event that could result in personal
injury or property damage. For example, if a person slips and falls, an injury may or
may not result, but an accident has taken place.

Heinrich’s Domino Theory – Corrective Action Sequence (The three “E”s):

• Engineering

 Control hazards through product design or process change

• Education

 Train workers regarding all facets of safety

 Impose on management that attention to safety pays off
• Enforcement

 Ensure that internal and external rules, regulations, and standard operating
procedures are followed by workers as well as management.

Human factors theory:

Heinrich posed his model in terms of a single domino leading to an accident.

The premise here is that human errors cause accidents. These errors are categorized
broadly as:

• OVERLOAD

The work task is beyond the capability of the worker

 Includes physical and psychological factors

 Influenced by environmental factors, internal factors, and situational factors

• INAPPROPRIATE WORKER RESPONSE

 To hazards and safety measures (worker’s fault)

 To incompatible work station (management, environment faults)

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• INAPPROPRIATE ACTIVITIES

 Lack of training and misjudgment of risk

But the structure of this theory is still a cause/effect format.

Accident/incident theory:
• Overload

The work task is beyond the capability of the worker

 Includes physical and psychological factors

 Influenced by environmental factors, internal factors, and situational factors
• Inappropriate worker response

 To hazards and safety measures (worker’s fault)

 To incompatible work station (management, environment faults)
• Inappropriate activities

 Lack of training and misjudgment of risk

• Ergonomic traps
 These are incompatible work stations, tools, or expectations (management
failure)
• Decision to err
 Unconscious or conscious (personal failure)
• Systems failure
 Management failure (policy, training, etc.)
Epidemiological theory:
Epidemiology

 This field studies relationship between environmental factors and disease

 Can be used to study causal factors in a relationship
Two key components:

1. Predisposition characteristics

• tendencies may predispose worker to certain actions

2. Situational characteristics

• peer pressure, poor attitude, risk-taking

Together these characteristics can cause or prevent accidents that a person predisposed
to a given situation or condition may succumb to.

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Systems Theory:
Accident arises from interactions among humans, machines, and the
environment.

• Not simply chains of events or linear causality, but more complex types of
causal connections.
Under normal circumstances chances of an accident is low. Rather than looking at
the environment as being full of hazards and people prone to errors, system safety
assumes harmony (steady-state) exists between individuals and the work environment

 Safety is an emergent property that arises when components of the system

interact with a large environment.
(a) A set of constraints related to the behavior of components in the
system enforces that property.
(b) Accidents when interactions violate those constraints. (Lack of
appropriate constraints on the interactions).
(c) Software as a controller embodies or enforces those constraints.

Systems Theory Applied to Transportation Engineering

What about weather conditions?

Vehicle

Driver Road infrastructure

Road accidents are seen as failures of the whole traffic system (interaction

between the three elements) rather than a failure of the driver.

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• The driver is a victim – this assumes the demands that the traffic system puts
on the driver is too complex for the driver’s limited capacity to process
information.
• As a result of this assumption, the system must be designed to be less complex,
which prevents errors from occurring.
• “The energy and barriers perspective”: The system must also reduce the
negative consequences of errors, i.e., introduce safety margins that allow the
driver to incur an error without being hurt too seriously.

BEHAVIORAL THEORY:

• Often referred to as behavior-based safety (BBS)

7 basic principles of BBS

 Intervention
 Identification of internal factors
 Motivation to behave in the desired manner
 Focus on the positive consequences of appropriate behavior
 Application of the scientific method
 Integration of information
 Planned interventions

Bird’s Triangle:

Accident triangles — often called Bird’s (or Heinrich’s) Triangle — are based
on a theory of industrial accident prevention, and particularly a human factors
approach to safety.

The above is a typical pyramid or triangular representation of the theory.

Essentially, it shows a statistical relationship between the number of major, minor,
and near misses, with the implication that if the number of minor accidents is reduced
then the number of serious accidents will correspondingly reduce. In this iteration, for

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every six hundred accidents with no injury or damage, there is likely to be one
involving serious or disabling injury.

It should be remembered that accident or Bird's Triangle is often generic terms

for updated or business-specific versions of triangles that have been created, ie they
don't necessarily use the original probabilities suggested by Heinrich or Bird, ie there
might not be a serious injury accident for every 10 minor injury accidents. To
complicate matters further, some triangles will also show a separate figure for
fatalities and some will show a distinction between unsafe acts and near misses.

The number of different versions is explained by their history. The version of

the Triangle was first postulated in 1931 by Herbert W Heinrich, in his
book Industrial Accident Prevention, A Scientific Approach. Then, in 1966, this was
updated by another American, Frank B Bird, who then refined this model over several
years along with other theories relating to accident causation.

While we will refer to Bird's Triangle in this article, the analysis will apply to
other versions and iterations that can be found in the generic accident triangles.

Multiple causation theory:

Multiple causation theory is an outgrowth of the domino theory, but it

postulates that for a single accident there may be many contributory factors, causes,
and sub-causes and that certain combinations of these give rise to accidents.
According to this theory, the contributory factors can be grouped into the following
two categories:

Behavioural:

This category includes factors about the worker, such as improper attitude, lack
of knowledge, lack of skills, and inadequate physical and mental condition.

Environmental.:

This category includes improper guarding of other hazardous work elements

and degradation of equipment through use and unsafe procedures.
The major contribution of this theory is to bring out the fact that rarely, if ever, is an
accident the result of a single cause or act.

The pure chance theory:

According to the pure chance theory, everyone of any given set of workers has
an equal chance of being involved in an accident. It further implies that there is no
single discernible pattern of events that leads to an accident. In this theory, all

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accidents are treated as corresponding to Heinrich’s acts of God, and it is held that
there exist no interventions to prevent them.

Biased liability theory:

Biased liability theory is based on the view that once a worker is involved in an
accident, the chances of the same worker becoming involved in future accidents are
either increased or decreased as compared to the rest of the workers. This theory
contributes very little if anything at all, towards developing preventive actions for
avoiding accidents.

Accident proneness theory:

Accident proneness theory maintains that within a given set of workers, there
exists a subset of workers who are more liable to be involved in accidents.
Researchers have not been able to prove this theory because most of the research work
has been poorly conducted and most of the findings are contradictory and
inconclusive. This theory is not generally accepted. It is felt that if indeed this theory
is supported by any empirical evidence at all, it probably accounts for only a very low
proportion of accidents without any statistical significance.

The energy transfer theory:

Those who accept the energy transfer theory put forward the claim that a
worker incurs injury or equipment suffers damage through a change of energy, and
that for every change of energy there is a source, a path, and a receiver. This theory is
useful for determining injury causation and evaluating energy hazards and control
methodology. Strategies can be developed which are either preventive, limiting, or
ameliorating concerning the energy transfer.

Control of energy transfer at the source can be achieved by the following means:
 Elimination of the source
 Changes made to the design or specification of elements of the work station
 Preventive maintenance.

The path of energy transfer can be modified by:

 The enclosure of the path
 Installation of barriers
 Installation of absorbers
 The positioning of isolators.

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The receiver of energy transfer can be assisted by adopting the following measures:
 Limitation of exposure
 Use of personal protective equipment.

The “symptoms versus causes” theory:

The “symptoms versus causes” theory is not so much a theory as an admonition
to be heeded if accident causation is to be understood. Usually, when investigating
accidents, we tend to fasten upon the obvious causes of the accident to the neglect of
the root causes. Unsafe acts and unsafe conditions are the symptoms—the proximate
causes—and not the root causes of the accident.

SHELL models:
Another conceptual tool, widely used in aviation, which analyses the
interaction between multiple system components, is SHELL, which stands for:
S = Software (any procedures, checklists, training, computer)
H = Hardware (machines and equipment- including the controls, instruments, and
interfaces)
E = Environment (conditions – oxygen, pressure, temperature, socioeconomic
considerations)
L = Liveware (any people involved in the workplace – pilots, cabin crew, ATC,
engineers, etc )
The Human to the human interface is in the middle of the model as it is
considered the important element and it is the main contributor and factor in aviation
safety. Our goal is to understand the interaction with the other components and
identify the way this interaction results in mistakes and errors. However, the
inconsistency in the human element brings up the following 4 P-factors which need to
be considered: Physical, Physiological, Psychological, and Psycho-social factors.

The constant interaction of the elements with liveware is what sets-up the
conditions and the basis for an event.

The advancement of SHELL produced the SCHELL, which has the addition of
Culture in the components, a factor that can greatly influence the interactions.

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