Health, Safety and Environment

8th Semester

Assignment # 1

Submitted By:

Class: ME – 13 – C

Name CMS ID
Waleed Nasir 394281
Muhammad Adil Saleem 372066
Muhammad Zorain Haider 366729
Saad ur Rehman 375769

School of Mechanical and Manufacturing Engineering (SMME)

National University of Sciences and Technology (NUST),
Islamabad
Introduction
Accidents and incidents in industrial, construction, and other high-risk environments
have always been a major concern for organizations because of the severe
consequences they can have - not only in terms of human life but also in financial
losses and environmental damage. Understanding the causes of accidents is crucial
for developing practical and effective ways to prevent them, manage risks, and improve
overall workplace safety. To address this need, various accident causation theories
have been developed over the years. These theories aim to explain the different factors
that contribute to accidents, helping us analyze what went wrong and how similar
incidents can be avoided in the future.

Accident causation theories offer structured methods to look beyond just the immediate
and obvious causes of an accident, such as unsafe actions or hazardous conditions.
They push us to dig deeper and examine underlying causes like poor safety culture,
lack of management oversight, and organizational failures. By doing so, these theories
become essential tools for safety professionals, engineers, and managers to investigate
accidents properly, identify gaps in safety systems, and create more effective preventive
measures.

Among the many theories proposed, Domino Theory (Heinrich's Model) and Single
Factor Theory are two well-known and widely used approaches that offer different
ways to think about accident causation. Domino Theory, introduced by Herbert W.
Heinrich in the early 20th century, views accidents as the result of a chain of related
events. According to this theory, if even one "domino" in this chain is removed — such
as an unsafe act or condition — the accident can be prevented. It emphasizes that both
human behavior and organizational issues play a role in causing accidents. In contrast,
Single Factor Theory takes a more simplified approach, suggesting that accidents
often stem from a single, primary cause, like human error or equipment failure. While
this theory may not capture the full complexity of some incidents, it is useful in cases
where a clear root cause can be identified.

In this report, both of these theories will be explained and then applied to a real
industrial accident to evaluate how well they help in analyzing the causes and
identifying preventive steps. This analysis will show how such theories can support
organizations in building safer workplaces and reducing risks for their employees.
Theory Summary
Domino Theory
The Domino Theory, developed by Herbert W. Heinrich in 1931, is one of the earliest
and most influential accident causation theories in industrial safety. Heinrich proposed
that accidents are not random events, but rather the result of a sequential chain of
events or factors, much like a line of dominos falling over. According to this theory,
removing or controlling one key factor in the sequence can prevent the accident
from happening.
The five dominos (Sequence of accidents causation)
Heinrich identified five key dominos, each representing a stage or cause leading up to
an accident:
S. Domino Description
No
1 Ancestry and The background, upbringing, and social conditions that
Social influence a person’s behavior and attitude toward safety.
Environment Examples include poor training, unsafe work culture, and lack
of supervision.
2 Fault of Personal shortcomings or errors, such as carelessness, lack
Person of knowledge, or negligence. These faults are often shaped
by the individual's environment.
3 Unsafe Act The immediate causes of an accident, including unsafe
and/or actions (e.g., ignoring safety rules) or unsafe conditions (e.g.,
Mechanical or faulty equipment).
Physical
Hazard
4 Accident The event itself, such as a fall, explosion, or collision,
resulting from the unsafe act or condition.
5 Injury The consequence of the accident, including physical harm,
damage to property, or environmental harm.
In conclusion, Domino Theory offers a simple yet powerful framework for
understanding how accidents occur as a result of a chain of events. By identifying and
removing unsafe acts, unsafe conditions, or organizational failures, it is possible to

break the chain and prevent accidents before they cause harm. Although the model
mainly focuses on human error, it highlights the importance of addressing both
behavioral and systemic factors to improve workplace safety. Domino Theory remains a
foundational tool in accident investigation and prevention, encouraging proactive
measures to create safer work environments.

Single Factor Theory

The Single Factor Theory is one of the simplest accident causation models. It
suggests that every accident is the result of a single, specific cause, and by identifying
and eliminating that cause, accidents can be prevented. This theory focuses on one
dominant factor that directly leads to an accident, such as human error, equipment
failure, or unsafe environmental conditions.

Key Concepts of Single Factor Theory

 Accidents have a single root cause that is responsible for the accident.
 Finding and removing that single case can prevent occurrence.
 Often used to quickly identify the most obvious cause of an accident.

Examples of Single Factors are:

 Human Error: Operator mistake, negligence, lack of skill.

 Mechanical Failure: Broken machine, faulty design, or equipment malfunction.
 Environmental Hazard: Slippery floor, poor lightning, or extreme temperature.

Although the Single Factor Theory, it has its limitations.

  It oversimplifies complex accidents, which often have multiple contributing
factors.
 Ignores deeper, systemic causes like poor management, inadequate safety
culture, or organizational failures.
 May lead to blaming individuals rather than addressing underlying issues.

Conclusion:

In conclusion, while the Single Factor Theory can be useful for identifying obvious and
immediate causes of accidents, it lacks the depth needed for analyzing complex
incidents where multiple factors are involved. Relying solely on this theory may overlook
hidden risks and systemic issues. Therefore, it is best applied to simple accidents or
used as a starting point for deeper investigations using more comprehensive models.

Case Study:
Chernobyl Nuclear Disaster (Ukraine, 1984)

The Chernobyl Nuclear Disaster occurred on April 26, 1986, at Reactor No. 4 of the
Chernobyl Nuclear Power Plant in Ukraine during a late-night safety test. Due to
operator errors and critical reactor design flaws, an uncontrollable reaction caused
a massive explosion and fire, releasing huge amounts of radioactive material into the
atmosphere. The disaster led to immediate deaths, long-term health impacts like
cancer, and widespread environmental contamination, making it the worst nuclear

accident in history.

Sequence of Events Leading to the Accident

 1. The safety test aimed to examine whether the reactor's turbines could produce
enough electricity to keep coolant pumps running during a loss of external power,
until emergency generators activated.
2. To conduct the test, operators disabled key safety systems, including the
automatic shutdown system and emergency core cooling system, to prevent
interference with test results.
3. The reactor was brought down to an unstable low power level, which created
conditions prone to a positive feedback loop of reactivity.
4. Untrained operators made several critical mistakes, including withdrawing too
many control rods, which increased reactor instability.
5. The combination of these errors led to a rapid increase in reactor core
temperature and pressure, causing a massive steam explosion that blew the
reactor apart.
6. A second explosion followed, likely due to hydrogen accumulation, igniting fires
that burned for days and released enormous amounts of radiation.

1. Application of Domino Theory to the Chernobyl Nuclear Disaster:

Ancestry and Social Environment:

 Poor safety culture within the Soviet nuclear industry.

 Lack of open communication and transparency about reactor design flaws.
 Pressure to complete tests quickly, leading to neglect of safety protocols.

Fault of Person (Human Error)

 Operators lacked proper training and were unaware of the full risks.
 Ignored or disabled safety systems during the test.
 Continued the experiment despite reactor instability and dangerous conditions.

Unsafe Acts and/or Mechanical/Physical Hazards

 Unsafe act: Deliberately shutting down critical safety mechanisms (e.g.,

emergency core cooling system).
 Design flaws in the RBMK reactor, including a positive void coefficient, making
the reactor unstable at low power.
 Poorly designed control rods, which initially increased reactivity when inserted.

Accident (Incident Occurrence)

 Reactor explosion and fire, caused by an uncontrollable power surge.

 Massive release of radioactive material into the environment

Injury (Damage and Consequences)

 Immediate deaths of plant workers and firefighters

  Long-term health effects, including cancer and radiation sickness.
 Environmental contamination affecting vast areas of Europe.
 Evacuation of thousands of residents from the exclusion zone.

Conclusion:

If any one of these "dominos" - such as improving operator training, addressing reactor
design flaws, or enforcing a strong safety culture - had been addressed, the chain
leading to the Chernobyl disaster could have been broken, preventing the catastrophic
outcome. This analysis highlights the importance of focusing not only on human errors
but also on systemic and organizational weaknesses in preventing industrial accidents.

2. Application of Single Factor Theory to the Chernobyl Nuclear

Disaster:

According to the Single Factor Theory, every accident has one main cause, and
eliminating that cause could prevent the accident. Applying this theory to the Chernobyl
Nuclear Disaster, the single dominant cause can be identified as human error during
the safety test.

Identified Single Factor: Human Error:

 The operators violated safety protocols and conducted the test under unsafe
reactor conditions.
 They disabled key safety systems (such as the emergency core cooling
system) to proceed with the test.
 Operators lacked proper knowledge about the reactor's unstable behavior at
low power.
 Despite clear signs of reactor instability, they continued with risky actions,
leading to the explosion.

Conclusion:

From the Single Factor Theory perspective, human error was the main cause of the
Chernobyl disaster. If the operators had followed safety procedures and had proper
training and understanding of the reactor's behavior, the accident might have been
avoided.

Findings and Recommendations:

The analysis of the Chernobyl Nuclear Disaster through Domino Theory and Single
Factor Theory shows that major industrial accidents are rarely caused by just one issue
— they usually result from a combination of factors like human mistakes, weak safety
culture, and design flaws. While the Single Factor Theory focuses on human error as
the main cause, the Domino Theory gives a broader picture, revealing how a series of
unsafe actions, management failures, and technical problems all contributed to the
disaster. This highlights the importance of not only focusing on individual mistakes but
also addressing deeper issues within the system. To prevent such accidents in the
future, organizations must focus on building a strong safety culture, ensuring thorough
training for operators, fixing design issues, and putting in place multiple layers of
protection. Overall, a more holistic approach that looks at both human behavior and
organizational systems is necessary to create safer workplaces and avoid catastrophic
failures.