Accident-causation
This document was uploaded by user and they confirmed that they have the permission to share it. If you are author or own the copyright of this book, please report to us by using this DMCA report form. Report DMCA
Overview
Download & View Accident-causation as PDF for free.
More details
- Words: 1,152
- Pages: 34
ACCIDENT CAUSATION Protect the Force Through Risk Management
AC1
Early Man
Protect the Force Through Risk Management
AC2
Industrial Revolution Factory managers reasoned that workers were hurt because — Number is Up Carelessness
People Error
ACCIDENT Act of God
Cost of doing Business PEOPLE PROBLEM Protect the Force Through Risk Management
AC3
Domino Theory 1932 First Scientific Approach to Accident/Prevention - H.W. Heinrich.
“Industrial Accident Prevention”
Social Environment and Ancestry
Fault of the Person (Carelessness)
Unsafe Act or Condition
Accident
Injury
Protect the Force Through Risk Management
AC4
MISTAKES OF PEOPLE
Heinrich’s Theorems ●
INJURY - caused by accidents.
●
ACCIDENTS - caused by an unsafe act – injured person or an unsafe condition – work place.
●
UNSAFE ACTS/CONDITIONS - caused by careless persons or poorly designed or improperly maintained equipment.
●
FAULT OF PERSONS - created by social environment or acquired by ancestry.
●
SOCIAL ENVIRONMENT/ANCESTRY - where and how a person was raised and educated. Protect the Force Through Risk Management
AC5
Heinrich’s Theory Corrective Action Sequence (The three “E”s)
Engineering
Education
Enforcement Protect the Force Through Risk Management
AC6
Modern Causation Model OPERATING ERROR
RESULT:
MISHAP (POSSIBLE)
-No damage or injury -Many fatalities -Major damage
Protect the Force Through Risk Management
AC7
Modern Causation ● ●
How accidents are caused & how to correct those causes. Parallels Heinrich's to a point.
Injury is called RESULT, indicating it could involve damage as well as personal injury and the result can range from no damage to the very severe.
The word MISHAP is used rather than Accident to avoid the popular misunderstanding that an accident necessarily involves injury or damage.
Finally, the term OPERATING ERROR is used instead of Unsafe Act & Unsafe condition. Protect the Force Through Risk Management
AC8
Examples Operating Errors:
Being in an unsafe position
Stacking supplies in unstable stacks
Poor housekeeping
Removing a guard Protect the Force Through Risk Management
AC9
Systems Defect
Revolutionized accident prevention A weakness in the design or operation of a system or program
Protect the Force Through Risk Management
AC10
Examples Systems defects include:
Improper assignment of responsibility
Improper climate of motivation
Inadequate training and education
Inadequate equipment and supplies
Improper procedures for the selection & assignment of personnel
Improper allocation of funds Protect the Force Through Risk Management
AC11
Modern Causation Model SYSTEM DEFECTS
OPERATING ERRORS
RESULT:
MISHAP (POSSIBLE)
Operating Errors occur because people make mistakes, but more importantly, they occur because of
-No damage or injury -Many fatalities -Major damage
SYSTEM DEFECTS Protect the Force Through Risk Management
AC12
Modern Causation Model Managers design the Systems COMMAND ERROR
SYSTEM DEFECTS
RESULT:
OPERATING ERRORS
MISHAP (POSSIBLE)
-No damage or injury -Many fatalities -Major damage
System defects occur because of
MANAGEMENT / COMMAND ERROR Protect the Force Through Risk Management
AC13
Safety Program Defect A defect in some aspect of the safety program that allows an avoidable error to exist.
Ineffective Information Collection
Weak Causation Analysis
Poor Countermeasures
Inadequate Implementation Procedures
Inadequate Control Protect the Force Through Risk Management
AC14
Safety Management Error A weakness in the knowledge or motivation of the safety manager that permits a preventable defect in the safety program to exist.
SAFETY MANAGEMENT ERROR Protect the Force Through Risk Management
AC15
Modern Causation Model SAFETY MANAGEMENT ERROR
SAFETY PROGRAM DEFECT
COMMAND ERROR
SYSTEM DEFECT
OPERATING ERROR
MISHAP
RESULTS Protect the Force Through Risk Management
AC16
Near-Miss Relationship
Initial studies show for each disabling injury, there were 29 minor injuries and 300 close calls/no injury. Recent studies indicate for each serious result there are 59 minor and 600 near-misses. INITIAL STUDIES
1 29 300
SERIOUS MINOR CLOSE CALL
RECENT STUDIES
1 59 600
SERIOUS MINOR CLOSE CALL
Protect the Force Through Risk Management
AC17
Seven Avenues There are seven avenues through which we can initiate countermeasures. None of these areas overlap. They are: Safety management error Safety program defect Management / Command error System defect Operating error Mishap Result Protect the Force Through Risk Management
AC18
Seven Avenues Potential countermeasures for each modern causation approach include:
1 SAFETY MANAGEMENT ERROR
2 3 4 5 6 7
TRAINING EDUCATION MOTIVATION TASK DESIGN Protect the Force Through Risk Management
AC19
Seven Avenues Potential countermeasures for each modern causation approach include:
2 1
SAFETY PROGRAM DEFECT
3 4 5 6 7
REVISE INFORMATION COLLECTION ANALYSIS IMPLEMENTATION Protect the Force Through Risk Management
AC20
Seven Avenues Potential countermeasures for each modern causation approach include:
3 1 2
COMMAND ERROR
4 5 6 7
TRAINING EDUCATION MOTIVATION TASK DESIGN Protect the Force Through Risk Management
AC21
Seven Avenues Potential countermeasures for each modern causation approach include:
4 1 2 3
SYSTEM DEFECT
5 6 7
DESIGN REVISION VIA-- SOP - REGULATIONS - POLICY LETTERS - STATEMENTS Protect the Force Through Risk Management
AC22
Seven Avenues Potential countermeasures for each modern causation approach include:
5 1 2 3 4
OPERATING ERROR
6 7
ENGINEERING TRAINING MOTIVATION
Protect the Force Through Risk Management
AC23
Seven Avenues Potential countermeasures for each modern causation approach include:
6 1 2 3 4 5
MISHAP
7
PROTECTIVE EQUIPMENT BARRIERS SEPARATION
Protect the Force Through Risk Management
AC24
Seven Avenues Potential countermeasures for each modern causation approach include:
7 1 2 3 4 5 6
RESULT CONTAINMENT FIREFIGHTING RESCUE EVACUATION FIRST AID
Protect the Force Through Risk Management
AC25
Army Systems Model A system is simply a group of interrelated parts which, when working together as they were designed to do, accomplish a goal. Using this analogy, an installation or organization can be viewed as a system. The elements of the Army Systems Model are: Task Person Training Environment Materiel Protect the Force Through Risk Management
AC26
Army Systems Model TASK • Communication Control • Arrangement • Demands on soldiers • Time aspects
Protect the Force Through Risk Management
AC27
Army Systems Model PERSON Selection
Motivation
• Mentally
• Positive
• Physically
• Negative
• Emotionally
• Retention
• Qualified
Protect the Force Through Risk Management
AC28
Army Systems Model TRAINING Types
Targets
Considerations
• Initial
• Operator
• Quality/Quantity
• Update
• Supervisor
• Remedial
• Management
Protect the Force Through Risk Management
AC29
Army Systems Model ENVIRONMENT • Noise • Weather • Facilities • Lighting • Ventilation Protect the Force Through Risk Management
AC30
Army Systems Model MATERIEL • Supplies • Equipment • Machine Design • Maintenance
Protect the Force Through Risk Management
AC31
Army Systems Model SAFETY MANAGEMENT ERROR SAFETY PROGRAM DEFECT
COMMAND ERROR
Army Systems Model • • • • •
Task Training Environment Materiel Person
SYSTEM DEFECT
RESULT
MISHAP
OPERATING ERROR
Protect the Force Through Risk Management
Protect the Force Through Risk Management
AC33
Protect the Force Through Risk Management
Protect the Force Through Risk Management
AC34
AC1
Early Man
Protect the Force Through Risk Management
AC2
Industrial Revolution Factory managers reasoned that workers were hurt because — Number is Up Carelessness
People Error
ACCIDENT Act of God
Cost of doing Business PEOPLE PROBLEM Protect the Force Through Risk Management
AC3
Domino Theory 1932 First Scientific Approach to Accident/Prevention - H.W. Heinrich.
“Industrial Accident Prevention”
Social Environment and Ancestry
Fault of the Person (Carelessness)
Unsafe Act or Condition
Accident
Injury
Protect the Force Through Risk Management
AC4
MISTAKES OF PEOPLE
Heinrich’s Theorems ●
INJURY - caused by accidents.
●
ACCIDENTS - caused by an unsafe act – injured person or an unsafe condition – work place.
●
UNSAFE ACTS/CONDITIONS - caused by careless persons or poorly designed or improperly maintained equipment.
●
FAULT OF PERSONS - created by social environment or acquired by ancestry.
●
SOCIAL ENVIRONMENT/ANCESTRY - where and how a person was raised and educated. Protect the Force Through Risk Management
AC5
Heinrich’s Theory Corrective Action Sequence (The three “E”s)
Engineering
Education
Enforcement Protect the Force Through Risk Management
AC6
Modern Causation Model OPERATING ERROR
RESULT:
MISHAP (POSSIBLE)
-No damage or injury -Many fatalities -Major damage
Protect the Force Through Risk Management
AC7
Modern Causation ● ●
How accidents are caused & how to correct those causes. Parallels Heinrich's to a point.
Injury is called RESULT, indicating it could involve damage as well as personal injury and the result can range from no damage to the very severe.
The word MISHAP is used rather than Accident to avoid the popular misunderstanding that an accident necessarily involves injury or damage.
Finally, the term OPERATING ERROR is used instead of Unsafe Act & Unsafe condition. Protect the Force Through Risk Management
AC8
Examples Operating Errors:
Being in an unsafe position
Stacking supplies in unstable stacks
Poor housekeeping
Removing a guard Protect the Force Through Risk Management
AC9
Systems Defect
Revolutionized accident prevention A weakness in the design or operation of a system or program
Protect the Force Through Risk Management
AC10
Examples Systems defects include:
Improper assignment of responsibility
Improper climate of motivation
Inadequate training and education
Inadequate equipment and supplies
Improper procedures for the selection & assignment of personnel
Improper allocation of funds Protect the Force Through Risk Management
AC11
Modern Causation Model SYSTEM DEFECTS
OPERATING ERRORS
RESULT:
MISHAP (POSSIBLE)
Operating Errors occur because people make mistakes, but more importantly, they occur because of
-No damage or injury -Many fatalities -Major damage
SYSTEM DEFECTS Protect the Force Through Risk Management
AC12
Modern Causation Model Managers design the Systems COMMAND ERROR
SYSTEM DEFECTS
RESULT:
OPERATING ERRORS
MISHAP (POSSIBLE)
-No damage or injury -Many fatalities -Major damage
System defects occur because of
MANAGEMENT / COMMAND ERROR Protect the Force Through Risk Management
AC13
Safety Program Defect A defect in some aspect of the safety program that allows an avoidable error to exist.
Ineffective Information Collection
Weak Causation Analysis
Poor Countermeasures
Inadequate Implementation Procedures
Inadequate Control Protect the Force Through Risk Management
AC14
Safety Management Error A weakness in the knowledge or motivation of the safety manager that permits a preventable defect in the safety program to exist.
SAFETY MANAGEMENT ERROR Protect the Force Through Risk Management
AC15
Modern Causation Model SAFETY MANAGEMENT ERROR
SAFETY PROGRAM DEFECT
COMMAND ERROR
SYSTEM DEFECT
OPERATING ERROR
MISHAP
RESULTS Protect the Force Through Risk Management
AC16
Near-Miss Relationship
Initial studies show for each disabling injury, there were 29 minor injuries and 300 close calls/no injury. Recent studies indicate for each serious result there are 59 minor and 600 near-misses. INITIAL STUDIES
1 29 300
SERIOUS MINOR CLOSE CALL
RECENT STUDIES
1 59 600
SERIOUS MINOR CLOSE CALL
Protect the Force Through Risk Management
AC17
Seven Avenues There are seven avenues through which we can initiate countermeasures. None of these areas overlap. They are: Safety management error Safety program defect Management / Command error System defect Operating error Mishap Result Protect the Force Through Risk Management
AC18
Seven Avenues Potential countermeasures for each modern causation approach include:
1 SAFETY MANAGEMENT ERROR
2 3 4 5 6 7
TRAINING EDUCATION MOTIVATION TASK DESIGN Protect the Force Through Risk Management
AC19
Seven Avenues Potential countermeasures for each modern causation approach include:
2 1
SAFETY PROGRAM DEFECT
3 4 5 6 7
REVISE INFORMATION COLLECTION ANALYSIS IMPLEMENTATION Protect the Force Through Risk Management
AC20
Seven Avenues Potential countermeasures for each modern causation approach include:
3 1 2
COMMAND ERROR
4 5 6 7
TRAINING EDUCATION MOTIVATION TASK DESIGN Protect the Force Through Risk Management
AC21
Seven Avenues Potential countermeasures for each modern causation approach include:
4 1 2 3
SYSTEM DEFECT
5 6 7
DESIGN REVISION VIA-- SOP - REGULATIONS - POLICY LETTERS - STATEMENTS Protect the Force Through Risk Management
AC22
Seven Avenues Potential countermeasures for each modern causation approach include:
5 1 2 3 4
OPERATING ERROR
6 7
ENGINEERING TRAINING MOTIVATION
Protect the Force Through Risk Management
AC23
Seven Avenues Potential countermeasures for each modern causation approach include:
6 1 2 3 4 5
MISHAP
7
PROTECTIVE EQUIPMENT BARRIERS SEPARATION
Protect the Force Through Risk Management
AC24
Seven Avenues Potential countermeasures for each modern causation approach include:
7 1 2 3 4 5 6
RESULT CONTAINMENT FIREFIGHTING RESCUE EVACUATION FIRST AID
Protect the Force Through Risk Management
AC25
Army Systems Model A system is simply a group of interrelated parts which, when working together as they were designed to do, accomplish a goal. Using this analogy, an installation or organization can be viewed as a system. The elements of the Army Systems Model are: Task Person Training Environment Materiel Protect the Force Through Risk Management
AC26
Army Systems Model TASK • Communication Control • Arrangement • Demands on soldiers • Time aspects
Protect the Force Through Risk Management
AC27
Army Systems Model PERSON Selection
Motivation
• Mentally
• Positive
• Physically
• Negative
• Emotionally
• Retention
• Qualified
Protect the Force Through Risk Management
AC28
Army Systems Model TRAINING Types
Targets
Considerations
• Initial
• Operator
• Quality/Quantity
• Update
• Supervisor
• Remedial
• Management
Protect the Force Through Risk Management
AC29
Army Systems Model ENVIRONMENT • Noise • Weather • Facilities • Lighting • Ventilation Protect the Force Through Risk Management
AC30
Army Systems Model MATERIEL • Supplies • Equipment • Machine Design • Maintenance
Protect the Force Through Risk Management
AC31
Army Systems Model SAFETY MANAGEMENT ERROR SAFETY PROGRAM DEFECT
COMMAND ERROR
Army Systems Model • • • • •
Task Training Environment Materiel Person
SYSTEM DEFECT
RESULT
MISHAP
OPERATING ERROR
Protect the Force Through Risk Management
Protect the Force Through Risk Management
AC33
Protect the Force Through Risk Management
Protect the Force Through Risk Management
AC34
More Documents from "Mark Cheney"
Definition-of-sexual-hara
December 2019 5
Give-first-aid-for-burns
December 2019 4
Medevac-101
December 2019 2
1332
December 2019 4
Ar 40-57 - Armed Forces Medical Examiners Program
December 2019 5