Professional Documents
Culture Documents
CAUSATION
Early Man
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
Domino Theory
1932 First Scientific Approach to Accident/
Prevention - H.W. Heinrich.
Social
Environment
and Ancestry
Fault of the
Person
(Carelessness)
Unsafe Act
or
Condition
Accident
Injury
MISTAKES OF PEOPLE
Protect the Force Through Risk Management
Heinrichs Theorems
Heinrichs Theory
Corrective Action Sequence
(The three Es)
Engineering
Education
Enforcement
Protect the Force Through Risk Management
Modern
Causation
Model
RESULT:
OPERATINGE
RROR
MISHAP
(POSSIBLE)
No damage
or injury
- Many fatalities
- Major damage
Modern Causation
Examples
Operating Errors:
Poor housekeeping
Removing a guard
Protect the Force Through Risk Management
Systems Defect
Revolutionized accident
prevention
A weakness in the
design or operation of
a system or program
10
Examples
Systems defects include:
11
Modern
Causation
Model
SYSTEM
DEFECTS
OPERATING
ERRORS
RESULT:
MISHAP
(POSSIBLE)
- No damage
or injury
- Many fatalities
- Major damage
SYSTEM DEFECTS
Protect the Force Through Risk Management
12
SYSTEM
DEFECTS
RESULT:
OPERATING
ERRORS
MISHAP
(POSSIBLE)
- No damage
or injury
- Many fatalities
- Major damage
13
Poor Countermeasures
Inadequate Control
Protect the Force Through Risk Management
14
SAFETY
MANAGEMENT
ERROR
Protect the Force Through Risk Management
15
SAFETY
PROGRAM
DEFECT
COMMAND
ERROR
SYSTEM
DEFECT
OPERATING
ERROR
MISHAP
RESULTS
Protect the Force Through Risk Management
16
Near-Miss Relationship
1
29
300
SERIOUS
MINOR
CLOSE CALL
RECENT STUDIES
1
59
600
SERIOUS
MINOR
CLOSE CALL
17
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
18
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
19
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
20
Seven Avenues
Potential countermeasures for each modern
causation approach include:
3
1 2
4 5 6 7
COMMAND
ERROR
TRAINING
EDUCATION
MOTIVATION
TASK DESIGN
21
Seven Avenues
Potential countermeasures for each modern
causation approach include:
4
1 2 3
SYSTEM
DEFECT
5 6 7
22
Seven Avenues
Potential countermeasures for each modern
causation approach include:
5
1 2 3 4
OPERATING
ERROR
6 7
ENGINEERING
TRAINING
MOTIVATION
23
Seven Avenues
Potential countermeasures for each modern
causation approach include:
6
1 2 3 4 5
MISHAP
PROTECTIVE EQUIPMENT
BARRIERS
SEPARATION
24
Seven Avenues
Potential countermeasures for each modern
causation approach include:
7
1 2 3 4 5 6
RESULT
CONTAINMENT
FIREFIGHTING
RESCUE
EVACUATION
FIRST AID
25
26
27
Motivation
Positive
Negative
Emotionally
Retention
Qualified
28
Targets
Considerations
Initial
Operator
Quality/Quantity
Update
Supervisor
Remedial
Management
29
30
31
COMMAND
ERROR
Army Systems
Model
RESULT
Task
Training
Environment
Materiel
Person
MISHAP
SYSTEM
DEFECT
OPERATING
ERROR
33
34