Faculty of Chemical

Engineering
Universiti Teknologi
MARA

Process Safety - CPE615

THEORIES OF ACCIDENT CAUSATION
QUIZ

 List four theories of accident

 Explain the term unsafe act

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 Give example of unsafe condition

 Define overburden

 Differentiate the term incident and accident

INCIDENT VERSUS ACCIDENT

 Incident: all undesired circumstances that

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have the potential to cause accidents.
 Accident: a sequence of events that produce
unintended injury, damage to property or the
environment, production losses, or increased
liabilities.
 Accident refers to the event, not the results
of the event.
A major accident – defined as one having the
potential to kill 3 or more people or damage a
specific area of the environment or cause
property damage and loss in excess of a
particular sum.

A minor accident – might arise when the

release of a substance can cause ill-
health/injury
NEAR MISS……..

 an unplanned event that

did not result in injury,

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illness, or damage – but
had the potential to do so.
 another term for this
event: “close call”
ACCIDENT PYRAMIDS
- ACCIDENT RATIOS

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1 Major
Accident
Major
Injury 10
Minor
29 Accident
Minor
Injury
30
Property Damage
300 Accidents
Incidents
(near miss)
600
Near miss
Frank E. Bird Jr
H.W. Heinrich (1931) (1969)
KEY QUESTIONS
Why do accidents occur?

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How do accidents occur?
What must we do to keep them
from happening?
WHY DO ACCIDENTS OCCUR?
 Wechoose to handle dangerous processes,
materials, energies

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 To make a living
 To provide society with desirable products
 Aslong as we choose to handle them, a
potential for loss events exist.

Things can be done to reduce their likelihood

and severity to negligible or tolerable levels.
HOW DO ACCIDENTS OCCUR?

There are several theories that

attempt to explain the occurrence

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of accidents.
Most widely used theories of
accident causation:
 Domino theory
 Human factors theory
 Accident/incident theory
 Sociotechnical system framework
DOMINO THEORY
 Herbert W. Heinrich, an early pioneer of
accident prevention and industrial safety.
 He studied 75,000 reports of accidents for

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insurance claims and concluded:
 88% of industrial accidents are caused
by unsafe acts committed by workers
 10% of industrial
accidents are caused by
unsafe conditions
 2% of industrial
accidents are
unavoidable.
HEINRICH’S AXIOM OF INDUSTRIAL SAFETY

 Injuries result from a complete series of

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factors, one of which is the accident itself
 An accident can occur as a result of unsafe
act and/or unsafe conditions
 Most accidents are the result of unsafe
behaviour by people
 An unsafe act or an unsafe conditions does
not immediately result in an accident/injury;
HEINRICH’S AXIOM OF INDUSTRIAL SAFETY

 The reasons why people commit unsafe acts

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can serve as helpful guides in selecting
corrective actions.
 The severity of an accident is largely fortuitous
and the factors that cause it are largely
preventable.
 The prevention techniques are analogous with
the best quality and productivity techniques.
HEINRICH’S AXIOM OF INDUSTRIAL SAFETY

 Management should assume responsibility

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for safety because it is in the best position to
get results.
 The supervisor is the key person in the
prevention of industrial accidents.
 In addition to the direct costs of an accident
(i.e. compensation, liability claims, medical
costs, and hospital expenses) there are also
hidden or indirect costs.
 5 FACTORS IN THE SEQUENCE OF EVENTS
LEADING UP TO AN ACCIDENT

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Social Fault of Unsafe Act
Environment Person or Accident Injury
and Ancestry (Carelessness) Condition
 5 FACTORS IN THE SEQUENCE OF EVENTS
LEADING UP TO AN ACCIDENT

 Ancestry and social environment

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 Negative character traits that might lead people
to behave in an unsafe manner can be inherited
or acquired as a result of the social environment.
 Fault of a person
 Negative character traits, whether inherited
or acquired, are why people behave in unsafe
manner and why hazardous conditions exist.
5 FACTORS IN THE SEQUENCE OF EVENTS
LEADING UP TO AN ACCIDENT

 Unsafe act/Unsafe conditions

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 Unsafe acts committed by people
 Unsafe conditions due to the presence of
mechanical/physical hazards
 Accidents
 Typically, accidents that result in injury are caused
by falls and the impact of moving objects
 Injury
 Typical injuries resulting from accidents include
laceration and fractures
Example of unsafe act:

 Operating without authority

 Failure to warn or secure
 Operating at improper speed
 Making safety devices inoperable
 Using defective equipment
 Using equipment improperly
 Failure to use PPE
 Improper loading, placement
 Servicing equipment in motion
Example of unsafe condition:
 Inadequate guards or protection
 Defective tools, equipment
 Congestion, bad housekeeping
 Inadequate warning system
 Fire and explosion hazards
 Hazardous atmospheric condition
 Excessive noise
 Inadequate illumination or ventilation
 IDENTIFY UNSAFE ACT AND UNSAFE
CONDITION OF THIS SCENARIO AT A
FACTORY.

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 DIFFERENTIATE UNSAFE ACT AND UNSAFE
CONDITION BY LISTING THE NUMBER
 Process Safety - CPE615
SCENARIO AT A FACTORY.
 HEINRICH’S THEORY HAS TWO CENTRAL
POINTS:

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 Injuries
are caused by the action of
preceding factors

• Removal of the central factor (unsafe

acts/hazardous conditions) negates the
action of the preceding factors and, in so
doing, prevents accidents and injuries.
REMOVAL OF UNSAFE ACTS/UNSAFE
CONDITIONS PREVENTS THE ACCIDENT

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Injury

Accident

Unsafe act/unsafe condition

Fault of a person

Ancestry and social environment

HUMAN FACTORS THEORY

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Attributes accidents to a chain of events
that were ultimately the result of human
error.
Overload

Inappropriate Inappropriate
activities response
 OVERLOAD

 Animbalance between a person’s capacity at

any given time and the load that a person is

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carrying in a given state.
• A person’s capacity is
the product of such
factors as his/her
ability, training, state
of mind, fatigue,
stress, and physical
conditions.
OVERLOAD

 Added burden
resulting from

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 Environmental factors
(noise, distractions, etc.);
 Situational factors (level
of risks, unclear
instructions, etc.); and
 Internal factors
(personal problems,
emotional stress, worry,
etc.)
 INAPPROPRIATE ACTIVITIES

 Examples of
inappropriate activities

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include:
 A person undertaking a task he
or she doesn’t know how to do
(performing tasks without
requisite training)
 A person misjudging the degree
of risk involved in a given task
and proceeding based on that
misjudgment.
INAPPROPRIATE RESPONSE

 How a person responds in a given situation

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can cause or prevent an accident.
 Inappropriate response include:
 A person detects a hazardous condition but does
nothing to correct it;
 A person removes a safeguard from a machine in
an effort to increase output; or
 A person disregards an established safety
procedure
 Such responses can lead to accidents.
ACCIDENT/INCIDENT THEORY

 This the extension of the human factors theory

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which was developed by Dan Petersen.
 Introduced such new elements as ergonomic
traps, the decision to err, and system failure.
 In this model, overload, ergonomic traps and
decision to err lead to human error.
 The system failure is an important
contribution of Petersen’s theory.
SOME WAYS THAT A SYSTEM FAILS -
PETERSEN
 Management does not establish a
comprehensive safety policy.

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 Responsibility and authority with regard to
safety are not clearly defined.
 Safety procedures such as measurement,
inspection, correction and investigation are
ignored or given insufficient attention.
 Employees do not receive proper orientation.

 Employees are not given sufficient safety

training.
 Petersen’s Accident/Incident
Theory

Overload Ergonomics Decisions to

Traps err
Pressure

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Fatigue Incompatible Misjudgment of
Motivation workstation the risk
Drugs Incompatible Unconscious
Alcohol expectation desire to err
Worry

Human
Error
System failure

Policy Accident
Responsibility
Training
Inspection
Corrections
Injury/ Damage
Standards
THE SOCIOTECHNICAL FRAMEWORK

 Every fault in an incident scenario will have

Process Safety - CPE615

been affected by root causes.
 Failures in large industrial system cannot be
considered solely in technical terms.
 The sociotechnical system approach
emphasises the individual, organisational,
management and technical aspects which
affect a system’s performance.
THE SOCIOTECHNICAL SYSTEM FRAMEWORK

External
system
System climate
Organization
management Procedures &
Practices
Communication &
information system Management
Site & plant
control
facilities
Operator
Working environment performance Engineering
integrity
 External systems are influences outside the
boundary of the system which affect it but
are not significantly affected by the system
itself.

 System climate includes influences such as

business factors corporate culture, safety
culture and technical know-how which exist
within the environment of the company.
ORGANISATION AND MANAGEMENT
 provides
the scope for decision-making and
problem-solving within a company.

 It is the structure within which processes and

roles are defined and allocated to meet the
functional requirement of the plant.
 This includes general conditions of work,
relationships formally defined by
organisational charts and job description.
 Resources provision should be sufficient and
adequately allocated to the various functions
such as finance, expertise, information,
equipment and emergency needs.
 Site and plant facilities address
 the plant design and its realisation,
 the layout of the site,
 safety issues of current engineering projects and
 consideration of the storage and transport of
materials.

 Engineering integrity refers to

 the reliability and availability of the plant - that
is, the hardware, machinery and its associated
control systems
 which need to be assured beginning from the
design of the plant and continue through to
fabrication, installation, operation and
maintenance.
MANAGEMENT CONTROL
 refersmore specifically to the management of
safety for this particular study.
 It includes factors such as the setting of standards,
performance indicators, priorities and targets,
maintaining and-improving those standard
 Decision-making functions, allocations of resources
are examples of activities in this subsystem.
 Supervisory is a key factor.
COMMUNICATION AND
INFORMATION

 refers
to the dissemination and processing of
information vital to the safe functioning of
the system.
 These include the provision of operating
procedures, plant logs, permit-to-work systems and
also emergency response information.
 Toxicity data, material safety data sheets (MSDS)
and operating parameters are elements to be noted
when reviewing this subsystem.
 Communication systems must be effective.
PROCEDURES AND PRACTICES
 provide clear instructions for conducting
activities in a safe manner in the-to-day running
of the operations.
 Rigorous and accurate procedures are the basis for
safe and reliable operation.
 Proper dissemination and training in use is
important in promoting good working practices.
WORKING ENVIRONMENT
 refers to the workplace and the conditions within
it.
 How the operators work and go about their task are
considered.
 It is helpful to consider features such as welfare, the
safety culture prevailing and the availability of
immediate supervision and support.
OPERATOR PERFORMANCE
 refers to the activities in which shop-floor
employees are involved.
 These are the individuals who have direct interaction
with the plant - operating staff, supervisors, fitters
and maintenance staff.
 It encompasses all aspects which directly affects staff
performance including level of training and skills,
workplace design, psychological and physiological
effects.
EXERCISE
 Incident VS Accident
 Major accident VS Minor Accidents

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 Accident VS Near miss

 List the theories of accident causation

 List the 5 factors in the sequence of events

leading up to an accident
 Immediate cause VS Root cause
 Human
Factors
Theory

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Overload Inappropriate Inappropriate
Response Activities
 Human
Factors
Theory

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Overload Inappropriate Inappropriate
Response Activities
Environmental
factors Performing task
Internal Factors Detecting hazard
but not correcting without the requisite
Situational training
Factors it
Removing Misjudging the
safeguards from degree of risk
machines & involved with a given
equipment tasks
Ignoring safety
CASE STUDY
 Mr harith is an apprentice machinist at ABC
plant. One day, his supervisor took a vacation for
one week. The management assigned him to
replace his supervisor. He is then given a task to

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handle the machine for the production of the day.
The management reminded him to handle the
machine in an appropriate manner as this
machine has constant reported failure. In a hurry
to be on schedule, and fearing the machine would
break down again, he ran his hand into the cutter
on his milling machine. After the accident, he
realized that he had forgotten to read the safety
procedure available next to the machine.
 Discuss this accident scenario based on the theory
of accident causation
 Purpose an accident scenario which relates the
human factors theory of accident causation

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