Although the role that human error plays in accident causation has been accepted for many

years, it is only recently that a lot of concerted effort has been put into detailed research into
human error in accidents.
ACCIDENT - an undesired event that results in personal injury or property damage.
Basic Theories of Accident Causation
Accident causation models were originally developed in order to assist people who had to
investigate occupational accidents, so that such accidents could be investigated effectively.
Knowing how accidents are caused is also useful in a proactive sense in order to identify what
types of failures or errors generally cause accidents, and so action can be taken to address
these failures before they have the chance to occur.

The Domino Theory
In 1931, the late H.W. Heinrich (Heinrich et al, 19801) presented a set of theorems known as
the axioms of industrial safety. The first axiom dealt with accident causation, stating that the
occurrence of an injury invariably results from a complicated sequence of factors, the last one
of which being the accident itself.
Alongside, he presented a model known as the domino theory as this accident sequence was
likened to a row of dominoes knocking each other down in a row. 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.
The accident is avoided, according to Heinrich, by removing one of the dominoes, normally the
middle one or unsafe act. This theory provided the foundation for accident prevention
measures aimed at preventing unsafe acts or unsafe conditions.
The first update of the Domino Theory was presented by Bird & Loftus [ Heinrich et al, 1980;
Bird & Germain, 19862]. This update introduced two new concepts;
The influence of management and managerial error;
Loss, as the result of an accident could be production losses, property damage or wastage of
other assets, as well as injuries.
This model (known as the International Loss Control Institute or ILCI model) is shown in the
figure below:

The domino model has been noted as a one-dimensional sequence of events. Accidents are
usually multi-factorial and develop through relatively lengthy sequences of changes and errors.
This has led to the principle of multiple causation.
According to Peterson 3(1978), behind every accident there lie many contributing factors,
causes and sub-causes. The theory of multiple causation is that these factors combine together,
in random fashion, causing accidents. So, during accident investigations, there is a need to
identify as many of these causes as possible, rather than just one for each stage of the domino
sequence.
The accident model is in reality an amalgam of both the domino and multi-causality theories,
such as that shown below.

Conclusion
All accidents whether major or minor are caused, there is no such thing as an accidental
accident!!
Very few accidents, particularly in large organisations and complex technologies are
associated with a single cause.
The causes of accidents are usually complex and interactive.
The Role of Human Error in Accidents
Beyond the technical issues two common points emerged strongly from the inquiries into these
accidents, which are:
The influence of human error in the chain of events leading to the accident;
Failures in the management and organisation of safety.
People can cause or contribute to accidents (or mitigate the consequences) in a number of
ways (HSE, 19994):
Through a failure a person can directly cause an accident. However, people tend not to make
such errors deliberately. We are often set up to fail by the way that our brain processes
information by our training, through the design of equipment and procedures and even through
the culture of the organisation that we work for.
People can make disastrous decisions even when they are aware of the risks. We can also
misinterpret a situation and act inappropriately as a result. Both of these can lead to the
escalation of an incident.
On the other hand we can intervene to stop potential accidents. Many companies have their
own anecdotes about recovery from a potential incident through the timely actions of
individuals. Mitigation of the possible effects of an incident can result from human
resourcefulness and ingenuity.
The degree of loss of life can be reduced by the emergency response of operators and crew.
Emergency planning and response including appropriate training can significantly improve
rescue situations.
The Traditional Concept of Human Error
Traditionally the promotion of safety has been largely reactive, concentrating on accident
investigation with the primary aim of avoiding repeat events. In part this arose from too simple
an approach to accident causation based on the apparent importance placed on the concept of
a single primary cause; either an unsafe act or an unsafe condition (as a result of the domino
theory). If the former were the case, responsibility was clear and blame could be apportioned, if
the latter, then a technical solution could be sought. In part this also arose from the fact that a
reactive approach, based on a single primary cause was also an easy approach to handle.
Taking a blame approach to human error in accidents provides little of use in terms of future accident
prevention. For example, if a man made a mistake which resulted in an accident and we work on the
basis of a blame approach then there are only three options available to us:
We accept that human error is inevitable, shrug your shoulders, tell him to be a bit more careful and
carry on as before with your fingers crossed.
Alternatively, we can say as he was responsible, we should discipline him, perhaps even sack him.
The third option is a half-way house whereby we give him the benefit of the doubt and decide that he
might need retraining. However, if all we have found out about the accident was that he was the
cause we have learnt nothing new on which to base the retraining. We will almost certainly therefore
be reduced to repeating the training which we know has already failed!
Unfortunately this is a pretty reasonable description of the approach to human error in accidents that
has existed in most industrial organisations for years. If accidents are to be prevented in the future it is
no use whatsoever to blame people for their mistakes unless we have a detailed understanding of
what caused the mistakes. Only by understanding all the issues which have caused (or could cause) an
accident can we identify the way to prevent future accidents
Classification of Human Errors
The term human error is wide and can include a great variety of human behaviour. Therefore, in
attempting to define human error, different classification systems have been developed to describe
their nature.
Active Failures have an immediate consequence and are usually made by front-line people such as
drivers, control room and machine operators. These immediately precede, and are the direct cause, of
the accident.
Latent failures are those aspects of the organisation which can immediately predispose active failures.
Common examples of latent failures include (HSE, 1999):
Poor design of plant and equipment;
Ineffective training;
Inadequate supervision;
Ineffective communications; and
Uncertainties in roles and responsibilities.
Latent failures are crucially important to accident prevention for two reasons:
1. If they are not resolved, the probability of repeat (or similar) accidents remains high regardless of
what other action is taken;
2. As one latent failure often influences several potential errors, removing latent failures can be a very
cost-effective route to accident prevention.
Classifying Active Failures
In his classification of active failures Reason (1990) distinguishes between intentional and unintentional
error. Intentional errors are described as violations, whilst unintentional errors are classified as either
slips/lapses or mistakes.




Slips and Lapses: These occur in routine tasks with operators who know the process well and are
experienced in their work:
They are action errors which occur whilst the task is being carried out;
They often involved missing a step out of a sequence or getting steps in the wrong order and
frequently arise from a lapse of attention;
Operating the wrong control through a lapse in attention or accidentally selecting the wrong gear are
typical examples.
Mistakes: These are inadvertent errors and occur when the elements of a task are being considered by
the operator. They are decisions that are subsequently found to be wrong, although at the time the
operator would have believed them to be correct.
Rule based mistakes occur when the operation in hand is governed by a series of rules. The error
occurs when an in appropriate action is tied to a particular event
Knowledge based errors occur in entirely novel situations when you are beyond your skills,
beyond the provision of the rules and you have to rely entirely on adapting your basic
knowledge and experience to deal with a new problem.
Violations are any deliberate deviation from the rules, procedures, instructions and regulations, which
are deemed necessary for the safe or efficient operation and maintenance of plant or equipment.
Breaches in these rules could be accidental/unintentional or deliberate. Violations occur for many
reasons, and are seldom wilful acts of sabotage or vandalism. The majority stem from a genuine desire
to perform work satisfactorily given the constraints and expectations that exist. Violations are divided
into three categories: routine, situational and exceptional (HSE,1999).
Routine Violations are ones where breaking the rule or procedure has become the normal way of
working. The violating behaviour is normally automatic and unconscious but the violation is recognised
as such, by the individual(s) if questioned. This can be due to cutting corners, saving time. or be due to a
belief that the rules are no longer applicable.
Situational Violations occur because of limitations in the employees immediate work space or
environment. These include the design and condition of the work area, time pressure, number of staff,
supervision, equipment availability, and design and factors outside the organisations control, such as
weather and time of day. These violations often occur when a rule is impossible or extremely difficult to
work to in a particular situation.
Exceptional Violations are violations that are rare and happen only in particular circumstances, often
when something goes wrong. They occur to a large extent at the knowledge based level. The individual
in attempting to solve a novel problem violates a rule to achieve the desired goal.

Latent Failures
Latent failures are the factors or circumstances within an organisation which increase the likelihood of
active failures.
Other latent failures, common in industry are:
Attitudes to Safety: The safety culture of an organisation is established, in part, by the attitudes to safety
shown by management and supervisory staff. Unless managers lead by example and visibly demonstrate
their commitment to safety, no amount of hard work in the preparation and establishment of rules and
procedures and in providing training will have any lasting effect.
Rules & Procedures: Rules and procedures provide the framework upon which safety assurance is built
and are claimed to be effective control measures. However this is little more than an assumption rather
than a proven reality. Studies have shown that safety rules and procedures are often:
Written negatively, concentrating on should not be done rather than on what should be done;
Impractical;
In conflict with other rules
Training: Within training programmes, little consideration is given to evaluating its effectiveness. It
cannot be assumed that by simply attending a training course means that one is adequately trained.
Other common problems with training programmes include:
Hazard awareness is often assumed rather than training;
Training should concentrate on what is safe, rather than unsafe, what to do, rather than what not to
do.
Training is not always consistent with the rules and procedures.
Equipment design & Maintenance: limitations in the standard of ergonomics applied to the design of the
equipment/plant increase the risk of human error. Whilst it is usual to associate design limitations with
unintentional errors, i.e. slips & mistakes, poor designs also create a strong motivation for operators to
violate safe working procedures.
Conclusion of Section
Human Error is more than operator/pilot error. Everyone can make errors no matter how well trained
and motivated they are.
It is useful to distinguish between active and latent failures. Active failures are those hands on
operator errors that immediately precede an accident. Latent failures are the factors or circumstances
within an organisation which increase the likelihood of active failures. Latent failures lie hidden until
they are triggered at some time in the future.
In the domino theory or chain described earlier in the course active failures are analogous to the
immediate cause and latent failures analogous to the underlying or root cause.

Strategies for Reducing Human Error
Reducing human error involves far more than taking disciplinary action against an individual. There are a
range of measures which are more effective controls including the design of the equipment, job,
procedures and training.
Actions for overcoming Active Failures
Slips and Lapses
Design improvement is the most effective route for eliminating the cause of this type of human error.
For example, typical problems with controls and displays that cause this type of error include:
Switches which are too close and can be inadvertently switched on or off;
Displays which force the user to bend or stretch to read them properly;
Critical displays not in the operators field of view;
Poorly designed gauges;
Displays which are cluttered with non-essential information and are difficult to read.
Mistakes
Training, for individuals and teams, is the most effective way for reducing mistake type human errors.
The risk of this type of human error will be decreased if the trainee understands the need for and
benefits from safe plans and actions rather than simply being able to recite the steps parrot fashion.
Training should be based on defined training needs and objectives, and it should be evaluated to see if it
has had the desired improvement in performance.
Violations
There is no single best avenue for reducing the potential for deliberate deviations from safe rules and
procedures. The avenues for reducing the probability of violations should be considered in terms of
those which reduce an individuals motivation to violate. These include:
Under-estimation of the risk
Real or perceived pressure from the boss t adopt poor work practices;
Pressure from work-mates to adopt their poor working practices;
Cutting corners to save time and effort
Addressing Latent Failures
The organisation must create an environment which:
reduces the benefit to an individual from violating rules.
Reduces the risk of an operator making slips/lapses and mistakes.
This can be done by identifying and addressing latent failures.
Examples of latent failures include:
Poor design of plant and equipment;
Impractical procedures,
Ineffective training;
Inadequate supervision;
Ineffective communications; and
Uncertainties in roles and responsibilities.



Accident Investigation

Important part of any safety management system. Highlights the reasons why accidents occur
and how to prevent them.
The primary purpose of accident investigations is to improve health and safety performance by:
Exploring the reasons for the event and identifying both the immediate and underlying
causes;
Identifying remedies to improve the health and safety management system by
improving risk control, preventing a recurrence and reducing financial losses.

What to Investigate?
All accidents whether major or minor are caused.

Serious accidents have the same root causes as minor accidents as do incidents with a
potential for serious loss. It is these root causes that bring about the accident, the
severity is often a matter of chance.

Accident studies have shown that there is a consistently greater number of less serious
accidents than serious accidents and in the same way a greater number of incidents
then accidents.

Many accident ratio studies have been undertaken and the one shown below is based on
studies carried out by the Health & Safety Executive.








Accident Studies
In all cases the non-injury incidents had the potential to become events with more
serious consequences.


189
Non Injury Accidents/Illnesses
7
Minor injuries or illnesses
1
Major injury
Or illness
Such ratios clearly demonstrate that safety effort should be aimed at all accidents
including unsafe practices at the bottom of the pyramid, with a resulting improvement
in upper tiers.

Peterson (1978) in defining the principles of safety management says that an unsafe
act, an unsafe condition, an accident are symptoms of something wrong within the
managements system.
All events represent a degree of failure in control and are potential learning
experiences. It therefore follows that all accidents should be investigated to some
extent.

This extent should be determined by the loss potential, rather then just the immediate
effect.
Stages in an Accident/Incident Investigation
The stages in an accident/incident investigation are shown in the following diagram.














Deal with immediate
risks.
Select the level of
investigation.
Investigate the event.
Record and analyse the
results.
Review the process.
Dealing with Immediate Risks
When accidents and incidents occur immediate action may be necessary to:
Make the situation safe and prevent further injury.
Help, treat and if necessary rescue injured persons.
An effective response can only be made if it has been planned for in advance.
Selecting the level of investigation
The greatest effort should be put into:
Those involving severe injuries, ill-health or loss.
Those which could have caused much greater harm or damage.
These types of accidents and incidents demand more careful investigation and management time. This
can usually be achieved by:
Looking more closely at the underlying causes of significant events.
Assigning the responsibility for the investigation of more significant events to
more senior managers.
Investigating the Event
The purpose of investigations is to establish:
The way things were and how they came to be.
What happened the sequence of events that led to the outcome.
Why things happened as they did analysing both the immediate and underlying causes.
What needs to be done to avoid a repetition and how this can be achieved.

A few sources should give the investigator all that is needed to know.





















Interviews
Interviewing the person(s) involved and witnesses to the accident is of prime importance, ideally
in familiar surroundings so as not to make the person uncomfortable.
The interview style is important with emphasis on prevention rather than blame.
The person(s) should give an account of what happened in their terms rather than the
investigators.
Interviews should be separate to stop people from influencing each other.
Questions when asked should not be intimidating as the investigator will be seen as aggressive
and reflecting a blame culture.
Observation

Observation
Information from physical
sources including:

Premises and place of

work

Access & egress

Plant & substances in use

Location & relationship of

physical particles

Any post event checks,

sampling or
reconstruction
Documents
Information from:

Written instructions;
Procedures, risk
assessments, policies

Records of earlier
inspections, tests,
examinations and
surveys.
Interviews
Information from:

Those involved and

their line
management;

Witnesses;

Those observed or
involved prior to the
event e.g. inspection
& maintenance staff.

Checking reliability, accuracy

Identifying conflicts and resolving differences

Identifying gaps in evidence

The accident site should be inspected as soon as possible after the accident. Particular
attention should/must be given to:

Positions of people.
Personnel protective equipment (PPE).
Tools and equipment, plant or substances in use.
Orderliness/Tidiness.
Documents
Documentation to be looked at includes:
Written instructions, procedures and risk assessments which should have been in operation and
followed. The validity of these documents may need to be checked by interview. The main
points to look for are:
Are they adequate/satisfactory?
Were they followed on this occasion?
Were people trained/competent to follow it?
Records of inspections, tests, examination and surveys undertaken before the event. These
provide information on how and why the circumstances leading to the event arose.
Determining Causes
Collect all information and facts which surround the accident.
Immediate causes are obvious and easy to find. They are brought about by unsafe acts and
conditions and are the ACTIVE FAILURES. Unsafe acts show poor safety attitudes and indicate a
lack of proper training.
These unsafe acts and conditions are brought about by the so called root causes. These are the
LATENT FAILURES and are brought about by failures in organisation and the managements
safety system.

Determine what changes are needed
The investigation should determine what control measures were absent, inadequate or not
implemented and so generate remedial action for implementation to correct this.
Generally, remedial actions should follow the hierarchy of risk control:
Eliminate Risks by substituting the dangerous by the inherently less dangerous.
Combat risks at source by engineering controls and giving collective protective measures priority.
Minimise risk by designing suitable systems of working.
Use PPE as a last resort.
Recording & Analysing the Results
Recorded in a similar and systematic manner.
Provides a historical record of the accident.
Analysis of the causes and recommended preventative protective measures should be listed.
Completed as soon after the accident as possible.
Information on the accident and remedial actions should be passed to all supervisors.
Appropriate preventative measures may also have to be implemented by such supervisors.
Investigation reports and accident statistics should be analysed from time to time to identify common
causes, features and trends not be apparent from looking at events in isolation

Reviewing the Process
Reviewing the accident/incident investigation process should consider:
The results of investigations and analysis.
The operation of the investigation system (in terms of quality and effectiveness).
Line managers should follow through and action the findings of investigations and analysis.
Follow up systems should be established where necessary to keep progress under control.

The investigation system should be examined from time to time to check that it consistently delivers
information in accordance with the stated objectives and standards. This usually requires:
Checking samples of investigation forms to verify the standard of investigation and the
judgements made about causation and prioritisation of remedial actions.
Checking the numbers of incidents, near misses, injury and ill-health events;
Checking that all events are being reported.


Incident Report

Typical Contents
Title, date and time
Location of the accident
Type of injury or damage/who and what was involved
Cost of losses
Description of what happened including emergency response sequence
How the accident occurred/extent of damage
Immediate(direct(energy sources, haz. materials etc.) & indirect causes(unsafe acts and
conditions) & basic causes (personal/environmental factors)
Lack of control(management policies)
Remedial actions temporary & permanent
Management review
Other
Note:
Timeliness of report is critical, best reports are written promptly
Accident reports are usually discoverable this means they can be used by parties to an action
for damages or criminal charges





Analysis of costs

Consider the following:
Cost of dealing with incident( such as first aid, emergency supplies, staff downtime)
Costs of incident investigation( such as staff time, consultants time)
Cost of getting back to business( such as re-scheduling, clean-up, hire of equipment)
Business Costs( such as cost of injured persons salary, replacement salary, lost orders)
UK HSE useful incident cost calculator template next slide

Accident Statistics Analysis

Accident data base should be established
Identify trends and focus systems where they can produce the greatest return on invested time
and energy
Accident analysis statistics should be:
produced regularly by the Safety Department
reviewed at regular management and safety committee meetings
summary available to all employees
Identify repetitive or signifcant items
Statistics may include:
Number of near-miss, property damage, first aid, medical aid, lost time incidents, fire,
environmental events
Lost time injury frequency rates and severity rates
Lost Time Incident Frequency Rate(LTIFR)=(Total Lost Time Incidents/Total Hours Worked) x
100,000
Lost Time Incident Severity Rate(LTIFR)=(Total hours lost/Total Hours Worked) x 100,000
Costs
Cause and control analysis
Type of accidents by department, work section, occupation
Equipment/substances involved
Activity at time of injury
Age of person/length of service
Time of day
Immediate causes(substandard acts and conditions)
Basic causes( Personal and job factors)
Lack of control(inadequate programme standards or compliance with standards)
Remedial action completion by department

Accident Investigation

Case Study
Form teams for the investigating and reporting
Analyse the facts
Identify the immediate and basic causes
Recommend remedial actions
Complete Incident Report
Present findings

Conclusion

WHEN AN ORGANIZATION REACTS SWIFTLY AND POSTIVELY TO ACCIDENTS AND INJURIES, ITS ACTIONS
REAFFIRM ITS COMMITMENT TO THE SAFETY AND WELL-BEING OF ITS EMPLOYEES





Bicol University
College of Engineering
Legazpi City





Accident escalation, incident investigation, and reporting





Submitted by: Abito Manlapaz III
Harold Kenneth L. Quong
Ralph Cedrick Llagas
BSEE 3 B
Submitted to: Engr Zendy Dematera