Mishap CAUSATION - PowerPoint PPT Presentation

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Mishap CAUSATION PowerPoint Presentation
Mishap CAUSATION

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adrienne-burke
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Mishap CAUSATION

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  1. ACCIDENT CAUSATION

  2. Early Man

  3. Factory managers reasoned that workers were hurt because — Industrial Revolution Number is Up Carelessness People Error ACCIDENT Cost of doing Business Act of God PEOPLE PROBLEM

  4. Social Environment and Ancestry Injury Unsafe Act or Condition Accident Fault of the Person (Carelessness) Domino Theory 1932 First Scientific Approach to Accident/Prevention - H.W. Heinrich. “Industrial Accident Prevention” MISTAKES OF PEOPLE

  5. 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. Heinrich’s Theorems

  6. Heinrich’s Theory Corrective Action Sequence (The three “E”s) • Engineering • Education • Enforcement

  7. Modern Causation Model • RESULT: • No damage • or injury • Many fatalities • Major damage OPERATINGERROR MISHAP (POSSIBLE)

  8. 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.

  9. Examples Operating Errors: • Being in an unsafe position • Stacking supplies in unstable stacks • Poor housekeeping • Removing a guard

  10. Systems Defect • Revolutionized accident prevention • A weakness in the design or operation of a system or program

  11. 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

  12. Modern Causation Model • RESULT: • No damage • or injury • Many fatalities • Major damage OPERATINGERRORS MISHAP (POSSIBLE) SYSTEM DEFECTS Operating Errors occur because people make mistakes, but more importantly, they occur because of SYSTEM DEFECTS

  13. Modern Causation Model Managers design the Systems COMMAND ERROR • RESULT: • No damage • or injury • Many fatalities • Major damage OPERATINGERRORS MISHAP (POSSIBLE) SYSTEM DEFECTS System defects occur because of MANAGEMENT / COMMAND ERROR

  14. 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

  15. 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

  16. Modern Causation Model SAFETY MANAGEMENT ERROR SAFETY PROGRAM DEFECT COMMAND ERROR SYSTEM DEFECT OPERATING ERROR MISHAP RESULTS

  17. 1 1 SERIOUS SERIOUS 29 59 MINOR MINOR 300 600 CLOSE CALL CLOSE CALL 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. RECENT STUDIES INITIAL STUDIES

  18. 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

  19. Potential countermeasures for each modern causation approach include: SAFETY MANAGEMENT ERROR 1 TRAINING EDUCATION MOTIVATION TASK DESIGN 2 3 4 5 6 7 Seven Avenues

  20. Potential countermeasures for each modern causation approach include: SAFETY PROGRAM DEFECT 1 3 4 5 6 7 Seven Avenues 2 REVISE INFORMATION COLLECTION ANALYSIS IMPLEMENTATION

  21. Potential countermeasures for each modern causation approach include: TRAINING EDUCATION MOTIVATION TASK DESIGN 1 2 4 5 6 7 Seven Avenues 3 COMMAND ERROR

  22. Potential countermeasures for each modern causation approach include: DESIGN REVISION VIA-- - SOP - REGULATIONS - POLICY LETTERS - STATEMENTS 1 2 3 5 6 7 Seven Avenues 4 SYSTEM DEFECT

  23. Potential countermeasures for each modern causation approach include: 5 ENGINEERING TRAINING MOTIVATION 1 2 3 4 6 7 OPERATING ERROR Seven Avenues

  24. Potential countermeasures for each modern causation approach include: MISHAP 6 PROTECTIVE EQUIPMENT BARRIERS SEPARATION 1 2 3 4 7 5 Seven Avenues

  25. Potential countermeasures for each modern causation approach include: RESULT CONTAINMENT FIREFIGHTING RESCUE EVACUATION FIRST AID 1 2 3 4 5 6 Seven Avenues 7

  26. 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

  27. Army Systems Model TASK • Communication Control • Arrangement • Demands on soldiers • Time aspects

  28. Army Systems Model PERSON • Selection • Mentally • Physically • Emotionally • Qualified • Motivation • Positive • Negative • Retention

  29. Army Systems Model TRAINING • Types • Initial • Update • Remedial • Targets • Operator • Supervisor • Management • Considerations • Quality/Quantity

  30. Army Systems Model ENVIRONMENT • Noise • Weather • Facilities • Lighting • Ventilation

  31. Army Systems Model MATERIEL • Supplies • Equipment • Machine Design • Maintenance

  32. SAFETY MANAGEMENT ERROR SAFETY PROGRAM DEFECT RESULT MISHAP OPERATING ERROR COMMAND ERROR Army Systems Model Army Systems Model • Task • Training • Environment • Materiel • Person SYSTEM DEFECT

  33. ARE THERE ANY QUESTIONS?