Lecture 5. Mr Nzimah (Continuation of lecture 4).pdf
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The document summarizes Heinrich's Domino Theory of accident causation. The theory proposes that accidents result from a chain of five sequential factors or "dominoes" falling over: 1) Social environment and ancestry influence 2) faults of a person that lead to 3) unsafe acts/conditions which then cause 4) an accident and finally 5) an injury. While providing an early framework, the theory is limited as it views accidents as a simple linear sequence rather than recognizing their multifaceted nature. More modern theories emphasize that accidents typically develop through complex interactions of multiple factors over time.
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BCJ 4385, Workplace Security 1 UNIT II STUDY GUIDE T.docx
BCJ 4385, Workplace Security 1
UNIT II STUDY GUIDE
Threats and Legal Aspects to Security
Course Learning Outcomes for Unit II
Upon completion of this unit, students should be able to:
1. Evaluate threats to safety and security within the private, corporate, and
local level.
2. Analyze the legal issues present within the private security profession
and the court of law.
3. Outline various crime causation theories and how this impacts
workplace security.
Unit Lesson
General Overview
Have you ever entered an area or a building and immediately felt as if you were
in imminent danger? Do you remember that feeling you get in your chest and gut
when you almost slip and fall on the wet tile floor in your house? Alternatively,
have you entered a building and felt like you were trying to enter an armory?
Have you ever been stopped in an arena or airport or even a shopping mall and
asked to provide your bag for searching? You’ve probably answered yes to at
least one of these questions. We have all, whether we realize it or not,
experienced threats to our safety and security and benefited from the legal
aspects of safety that help provide ethical standards and expectations for the
maintenance of safety.
Threats to safety and security can be intentional or unintentional and, as such,
have numerous sources. These sources range from accidents and human error,
to natural and environmental disasters, to civil disorder and crime. For example,
identity theft is a major concern since much of the commerce transactions are
now done online. Oftentimes the theft is a result of human error, such as not
shredding documents that contain personal information or not using a secure
web browser to conduct transactions. Human error is also exhibited when
employees do not properly handle merchandise, resulting in its theft, damage, or
lack of repair. Natural disasters are said to be a direct result of “the forces of
nature.” We often see natural disasters in the form of forest fires, earthquakes,
and tsunamis. On the other hand environmental disasters are the result of
hazardous materials being released into the environment. These types of
disasters are the result of some type of hazardous materials being released in
larger amounts into the environment (e.g., oil spill, leakage of nuclear reactors).
Fire and environmental disasters are examples of how the sources of the threats
to security and safety can be hard to identify and/or intertwined. A fire can be
started by lightning, it can result from human error that causes a spark (e.g., a
loose metal chain being dragged across concrete at high speeds), or it can result
from intentional criminal behavior, in which an arsonists sets a fire to cause
widespread damage. An environmental disaster, such as an oil spill, may have
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BOS 3651, Total Environmental Health and Safety Managemen.docx
BOS 3651, Total Environmental Health and Safety Management 1
Course Learning Outcomes for Unit II
Upon completion of this unit, students should be able to:
7. Examine management tools necessary to implement effective safety management systems.
7.1 Discuss the need for a safety management system to focus on serious injuries and fatalities.
7.2 Explain how human behavior and workplace processes combine to create the potential for
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Chapter 3:
Innovations in Serious Injury and Fatality Prevention
Chapter 4:
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Serious injuries and human error play pivotal roles in the success of any accident prevention effort. The costs
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UNIT x STUDY GUIDE
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In the course textbook, Manuele (2014) challenges the notion that if we eliminate all the minor injuries, the
severe injuries will be taken care of as well. The accident pyramid concept first proposed by H.W. Heinrich in
the 1930s has been embraced by safety professionals for decades.
Manuele (2014) presents some compelling evidence that perhaps we need to focus on the top of the pyramid
rather than the bottom. His research has demonstrated that incident frequency may have been reduced over
the past several decades, but severity has not decreased proportionately. He also shows that serious injuries
most often occur in nonroutine and nonproduction activities.
On what do safety professionals focus most of their prevention efforts? Routine and production activities! Of
course, increased exposure increases the risk, but if we are not experiencing serious injuries in these routine
operations, maybe we have them under control and should focus more of our efforts on the nonroutine. Keep
in mind that one fatal injury can quickly undo years of safety program building.
Trying to identify the nonroutine operations is reminiscent of former Secretary of Defense Donald Rumsfeld’s
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This document discusses theories of accident causation and investigation. It describes the single factor theory, which states that there is usually a single cause of accidents. However, this theory is limited as it overlooks other contributing factors. The document then explains domino theories of accident causation. Domino theories divide accidents into three phases - precontact, contact, and postcontact. Specific domino theories developed by Heinrich and Bird and Loftus are described. These theories emphasize that unsafe acts and conditions must be addressed and prevented by management to eliminate accidents and related losses.
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Achieving a safe culture: theory and practice
JAMES R E A S O N
Department of Psychology, University of Manchester, Manchester M13 9PL, UK
Keywords: Safety culture; Accidents; Organizational factors; H u m a n error.
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considers why it is that an unsafe culture is more likely to be involved in the causation of organizational
rather than individual accidents. It is the pervasive nature of culture that makes it uniquely suitable
for creating and sustaining the co-linear gaps in defences-in-depth through which an accident
trajectory has to pass. The second topic relates to pathological adaptations, and discusses two
examples: the Royal Navy of the mid-nineteenth century and the Chernobyl reactor complex. The
third issue deals with recurrent accident patterns and considers the role of cultural drivers in creating
typical accidents. The final topic is concerned with the practical question of whether a safety culture
can be engineered. It is argued that a safe culture is an informed culture and this, in turn, depends upon
creating an effective reporting culture that is underpinned by a just culture in which the line between
acceptable and unacceptable behaviour is clearly drawn and understood.
1. Introduction
Although there is no universally accepted definition of safety culture, there can be little
doubt that it is a concept whose time has come. Since the beginning of 1997, there have been
well-attended meetings and workshops devoted exclusively to this topic, and the interest
extends across many work domains. For example, the US National Transportation Safety
Board’s (NTSB) symposium on ‘ Corporate Culture and Transportation Safety ’ in April
1997 attracted some 550 delegates from all of its constituencies : aviation, railroads,
highways, the marine world, pipelines and the safety of hazardous materials. The
symposium was convened because the NTSB’s accident investigators were increasingly
conscious of the crucial role played by cultural factors in creating bad events (see, for
example, NTSB/AAR 1994, 1997, NTSB/RAR 1996).
The high level of concern with organizational culture in the world of hazardous
technologies poses both a challenge and an opportunity for those academics involved in the
safety-related sciences. W e need to develop a clearer theoretical understanding of these
organizational issues to create a principled basis for more effective culture-enhancing
practices. To this end, the paper presents arguments dealing with four culture-related issues,
three largely theoretical and one with more directly practical applications.
First, are modern, high-tech, well-defended technologies-such as nuclear power plants,
chemical process plants and commercial aviation-more vulnerable to the effects of a poor
safety culture than traditional industries involv.
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Physical risk control aims to avoid, reduce, or prevent risks and losses. It can be achieved through three approaches: avoiding risks that are too great, preventing losses by reducing the probability of events occurring, and reducing the severity of possible losses. Several safety theories provide frameworks for physical risk control. The chain theory views controlling losses as breaking links in a chain. The domino theory proposes that accidents are the result of a series of factors knocking each other over, like dominoes. Haddon's energy transfer approach focuses on handling sudden releases of energy that can cause accidents.
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UNIT II STUDY GUIDE
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Course Learning Outcomes for Unit II
Upon completion of this unit, students should be able to:
1. Evaluate threats to safety and security within the private, corporate, and
local level.
2. Analyze the legal issues present within the private security profession
and the court of law.
3. Outline various crime causation theories and how this impacts
workplace security.
Unit Lesson
General Overview
Have you ever entered an area or a building and immediately felt as if you were
in imminent danger? Do you remember that feeling you get in your chest and gut
when you almost slip and fall on the wet tile floor in your house? Alternatively,
have you entered a building and felt like you were trying to enter an armory?
Have you ever been stopped in an arena or airport or even a shopping mall and
asked to provide your bag for searching? You’ve probably answered yes to at
least one of these questions. We have all, whether we realize it or not,
experienced threats to our safety and security and benefited from the legal
aspects of safety that help provide ethical standards and expectations for the
maintenance of safety.
Threats to safety and security can be intentional or unintentional and, as such,
have numerous sources. These sources range from accidents and human error,
to natural and environmental disasters, to civil disorder and crime. For example,
identity theft is a major concern since much of the commerce transactions are
now done online. Oftentimes the theft is a result of human error, such as not
shredding documents that contain personal information or not using a secure
web browser to conduct transactions. Human error is also exhibited when
employees do not properly handle merchandise, resulting in its theft, damage, or
lack of repair. Natural disasters are said to be a direct result of “the forces of
nature.” We often see natural disasters in the form of forest fires, earthquakes,
and tsunamis. On the other hand environmental disasters are the result of
hazardous materials being released into the environment. These types of
disasters are the result of some type of hazardous materials being released in
larger amounts into the environment (e.g., oil spill, leakage of nuclear reactors).
Fire and environmental disasters are examples of how the sources of the threats
to security and safety can be hard to identify and/or intertwined. A fire can be
started by lightning, it can result from human error that causes a spark (e.g., a
loose metal chain being dragged across concrete at high speeds), or it can result
from intentional criminal behavior, in which an arsonists sets a fire to cause
widespread damage. An environmental disaster, such as an oil spill, may have
resulted from an accident, such as two ships colliding or some mechanical
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This document discusses causation theories for analyzing accidents, including the domino theory and multiple causation theory. The domino theory proposes that accidents result from a chain of sequential causes, while multiple causation theory recognizes that accidents often have multiple interconnected causes occurring simultaneously. The document also covers topics like unsafe acts versus unsafe conditions, calculating accident rates, accident investigation and reporting procedures, and using investigation records to identify accident prevention strategies.
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Course Learning Outcomes for Unit II
Upon completion of this unit, students should be able to:
7. Examine management tools necessary to implement effective safety management systems.
7.1 Discuss the need for a safety management system to focus on serious injuries and fatalities.
7.2 Explain how human behavior and workplace processes combine to create the potential for
serious injuries.
Reading Assignment
Chapter 3:
Innovations in Serious Injury and Fatality Prevention
Chapter 4:
Human Error Avoidance and Reduction
Chapter 5:
Macro Thinking: The Socio-Technical Model
Unit Lesson
Serious injuries and human error play pivotal roles in the success of any accident prevention effort. The costs
and other consequences created by accidents dictate the need for changes that will ensure a reduction in
their occurrence. Discussing serious injuries and human error in this unit will better prepare us to tackle the
details of safety management systems and ANSI/AIHA Z10 in subsequent units.
UNIT II STUDY GUIDE
Serious Injury Prevention
and Human Error Reduction
Safety pyramid based on H. W. Heinrich’s study of industrial accidents. “Heinrich’s Law”
proposed that for every major injury 29 minor injuries and 300 noninjury incidents occur
(Heinrich, 1931).
BOS 3651, Total Environmental Health and Safety Management 2
UNIT x STUDY GUIDE
Title
In the course textbook, Manuele (2014) challenges the notion that if we eliminate all the minor injuries, the
severe injuries will be taken care of as well. The accident pyramid concept first proposed by H.W. Heinrich in
the 1930s has been embraced by safety professionals for decades.
Manuele (2014) presents some compelling evidence that perhaps we need to focus on the top of the pyramid
rather than the bottom. His research has demonstrated that incident frequency may have been reduced over
the past several decades, but severity has not decreased proportionately. He also shows that serious injuries
most often occur in nonroutine and nonproduction activities.
On what do safety professionals focus most of their prevention efforts? Routine and production activities! Of
course, increased exposure increases the risk, but if we are not experiencing serious injuries in these routine
operations, maybe we have them under control and should focus more of our efforts on the nonroutine. Keep
in mind that one fatal injury can quickly undo years of safety program building.
Trying to identify the nonroutine operations is reminiscent of former Secretary of Defense Donald Rumsfeld’s
“known knowns and unknown knowns” comments from a few years ago. Or was it “known unknowns”?
Whatever—the point is that we need to examine our safety culture to see if it supports identification of the
unknowns. Is incident reporting supported by policies that do not place blame? Does the incident investigation
...
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This document discusses theories of accident causation and investigation. It describes the single factor theory, which states that there is usually a single cause of accidents. However, this theory is limited as it overlooks other contributing factors. The document then explains domino theories of accident causation. Domino theories divide accidents into three phases - precontact, contact, and postcontact. Specific domino theories developed by Heinrich and Bird and Loftus are described. These theories emphasize that unsafe acts and conditions must be addressed and prevented by management to eliminate accidents and related losses.
WORK & STRESS, 1998, VOL. 12, NO. 3 293-306 Achieving a sa.docx
WORK & STRESS, 1998, VOL. 12, NO. 3 293-306
Achieving a safe culture: theory and practice
JAMES R E A S O N
Department of Psychology, University of Manchester, Manchester M13 9PL, UK
Keywords: Safety culture; Accidents; Organizational factors; H u m a n error.
This paper discusses four topics relating to safety culture, three theoretical and one practical. The first
considers why it is that an unsafe culture is more likely to be involved in the causation of organizational
rather than individual accidents. It is the pervasive nature of culture that makes it uniquely suitable
for creating and sustaining the co-linear gaps in defences-in-depth through which an accident
trajectory has to pass. The second topic relates to pathological adaptations, and discusses two
examples: the Royal Navy of the mid-nineteenth century and the Chernobyl reactor complex. The
third issue deals with recurrent accident patterns and considers the role of cultural drivers in creating
typical accidents. The final topic is concerned with the practical question of whether a safety culture
can be engineered. It is argued that a safe culture is an informed culture and this, in turn, depends upon
creating an effective reporting culture that is underpinned by a just culture in which the line between
acceptable and unacceptable behaviour is clearly drawn and understood.
1. Introduction
Although there is no universally accepted definition of safety culture, there can be little
doubt that it is a concept whose time has come. Since the beginning of 1997, there have been
well-attended meetings and workshops devoted exclusively to this topic, and the interest
extends across many work domains. For example, the US National Transportation Safety
Board’s (NTSB) symposium on ‘ Corporate Culture and Transportation Safety ’ in April
1997 attracted some 550 delegates from all of its constituencies : aviation, railroads,
highways, the marine world, pipelines and the safety of hazardous materials. The
symposium was convened because the NTSB’s accident investigators were increasingly
conscious of the crucial role played by cultural factors in creating bad events (see, for
example, NTSB/AAR 1994, 1997, NTSB/RAR 1996).
The high level of concern with organizational culture in the world of hazardous
technologies poses both a challenge and an opportunity for those academics involved in the
safety-related sciences. W e need to develop a clearer theoretical understanding of these
organizational issues to create a principled basis for more effective culture-enhancing
practices. To this end, the paper presents arguments dealing with four culture-related issues,
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First, are modern, high-tech, well-defended technologies-such as nuclear power plants,
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1.)
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3. Although psychology has a place in safety management, the emphasis Heinrich gave to it as
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unsafe acts, 10 percent are unsafe mechanica.
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Occupational health and safety aims to promote worker well-being and prevent harm in the workplace. It involves identifying hazards, evaluating risks, and implementing controls such as eliminating hazards, substituting safer materials, using engineering controls, administrative controls like training, and personal protective equipment. Common hazards include physical, chemical, biological and ergonomic factors. Occupational health also encompasses hygiene, medicine and a worker's right to privacy regarding medical information. Proper management of issues like housekeeping, waste disposal and spills is important for safety on work sites.
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1.)
The Occupational Safety and Health Administration, or OSHA, was established in 1970 to
encourage employees and employers to decrease workplace hazards. OSHA recommends that
both parties cooperatively establish workplace-specific safety standards. The agency also
establishes training programs for occupational safety and health personnel. Finally, OSHA
oversees research to find new approaches to workplace safety and health issues, according to
Princeton University Environmental Health and Safety Department.
OSHA has had significant effects on workplace safety. Although U.S. employment has almost
doubled, workplace fatalities have gone down by more than 65 percent since OSHA’s inception.
There were about 38 worker deaths a day in 1970 as compared to 13 per day in 2011.
Occupational injury and illness rates have also lowered noticeably. In 1972 the workforce
experienced about 10.9 incidents per 100 workers as compared to fewer than 4 per 100 in 2010.
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rewards you with increased productivity and higher morale as well.
2.)
Industrial safety expert, H.W. Heinrich’s 10 axioms of industrial safety stem from his domino
theory. He said injuries occur due to a series of preventable incidents or factors. An accident
occurs as the last step or last falling domino.
\"Heinrich Revisited: Truisms or Myths\" by Fred A. Manuele, CSP, PE [2002, ISBN 0-87912-
245-5 published by National Safety Council offers the following in the last chapter. \"The intent
of this book is to present a review of the origin of certain of Heinrich\'s premises that became
accepted as truisms, how they evolved and changed over time, and to determine their validity. A
summary of the observations made in this book follows.
1. Files pertaining to Heinrich\'s research do not exist. Thus, there is no material to review as the
quality of research, or the analytical system used to arrive at his premises or their validity.
2. Heinrich\'s studies were made of accidents that occurred in the 1920s. Safety at work and the
workplace itself have changed substantively since then, as evidenced by noteworthy reductions
in accident experience in the past 70 years. Therefore, the current value and applicability of his
conclusions should be questioned and researched.
3. Although psychology has a place in safety management, the emphasis Heinrich gave to it as
being \"a fundamental of great importance in accident causation\" was disproportionate, and that
overemphasis influenced his work considerably.
4. Heinrich\'s 88-10-2 ratios indicate that among the direct and proximate causes, 88 percent are
unsafe acts, 10 percent are unsafe mechanica.
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- 1. LECTURE 5 Mr. O.M. Nzimah oswardnzimah@outlook.com BA. EED University of Zambia OCCUPATION HEALTH AND SAFTEY
- 2. ACCIDENT AND INCIDENT INVESTIGATION 1 WHAT CAUSE ACCIDENTS? 2 ACCIDENT CAUSATION THEORIES 3 BACKGROUND
- 3. ACCIDENT AND INCIDENT INVESTIGATION 1 Learning objectives At the end of this lesson, you should be able to: Describe the causes of accidents Explain the theories of accident causation
- 4. INTRODUCTION This topic gives you an opportunity to find out what went wrong. Learning the lessons and taking action may reduce, or even prevent, accidents in the future.
- 5. ACCIDENT CAUSATION THEORIES Occupational accidents, work related injuries and fatalities result from multiple causes. Many attempts have been made to develop a prediction theory of accident causation. Researchers in the field of OSH have been trying for decades to understand what causes accidents but so far none has been universally accepted.
- 6. According to the domino theory; 88% of all accidents are caused by unsafe acts of people 10% by unsafe actions 2% by "acts of God". THE DOMINO THEORY
- 7. PREMISE OF THE THEORY It proposed a "five-factor accident sequence" in which each factor would actuate the next step in the manner of toppling dominoes lined up in a row. The sequence of accident factors is as follows
- 8. Heinrich's Domino Theory states that accidents result from a chain of sequential Events. Metaphorically like a line of dominoes falling over. When one of the dominoes falls, it triggers the next one, and the next... but removing a key factor (such as an unsafe condition or an unsafe act) prevents the start of the chain reaction. This means that an accident is avoided, according to Heinrich
- 9. The sequence is:- • Injury, caused by an; • Accident, due to an; • Unsafe act and/or mechanical or physical hazard, due to the; • Fault of the Person, caused by their; • Ancestry and Social Environment.
- 11. Removal of one of the factors would prevent the accident and resultant injury, with the key domino to be removed from the sequence being number 3. Although the author provided no data for his theory, it nonetheless represents a useful point to start discussion and a foundation for future research.
- 12. Heinrich's Domino Theory states that accidents result from a chain of sequential Events. Metaphorically like a line of dominoes falling over. When one of the dominoes falls, it triggers the next one, and the next... but removing a key factor (such as an unsafe condition or an unsafe act) prevents the start of the chain reaction. This means that an accident is avoided, according to Heinrich
- 13. Social Environment and Ancestry: This first domino in the sequence deals with worker personality. Heinrich explains that undesirable personality traits, such as stubbornness, greed, and recklessness can be "passed along through inheritance" or develop from a person's social environment. Theses contribute to Faults of Person.
- 14. Fault of Person: The second domino also deals with worker personality traits. Heinrich explains that inborn or obtained character flaws such as bad temper, inconsiderateness, ignorance, and recklessness contribute to accident causation. According to Heinrich, nature or environmental flaws in the worker's family or life cause these secondary personal defects, which are themselves contributors to Unsafe Acts, or and the existence of Unsafe Conditions.
- 15. Unsafe Act and/or Unsafe Condition: The third domino deals with Heinrich's direct cause of incidents. Heinrich defines these factors as things like "starting machinery without warning ... and absence of rail guards.” Heinrich felt that unsafe acts and unsafe conditions were the central factor in preventing incidents, and the easiest causation factor to remedy. Heinrich defines four reasons why people commit unsafe acts 1. "improper attitude, 2. lack of knowledge or skill, 3. physical unsuitability, 4. [and] improper mechanical or physical environment."
- 16. He later goes on to subdivide these categories into "direct" and "underlying" causes. For example, he says, a worker who commits an unsafe act may do so because he or she is not convinced that the appropriate preventative measure is necessary, and because of inadequate supervision.
- 17. Accident: Heinrich says, "The occurrence of a preventable injury is the natural culmination of a series of events or circumstances which invariably occur in a fixed and logical order." He defines accidents as, "events such as falls of persons, striking of persons by flying objects are typical accidents that cause injury."
- 18. Injury: Injury results from accidents, and some types of injuries Heinrich specifies in his "Explanation of Factors" are cuts and broken bones. To be fair to Heinrich, he does insist that "the responsibility lies first of all with the employer." Heinrich specifies that a truly safety-conscious manager will make sure his "foremen" and "workers" do as they told, and "exercise his prerogative and obtain compliance ... follow through and see the unsafe conditions are eliminated." Heinrich's remedy for such non-compliance is strict supervision, remedial training, and discipline.
- 19. Weakness of Domino Theory: The domino theory has been noted as a one dimensional sequence of events. Accidents are usually multi-factoral and develop through relatively lengthy sequences of changes and errors’. This has led to the theory of multiple causation.
- 20. END OF LECTURE 5