Accident Causation. Presented by: Lance Hofmann Director of Environmental Health & Safety EagleMed LLC

Transcription

1 Accident Causation Presented by: Lance Hofmann Director of Environmental Health & Safety EagleMed LLC

2 Agenda o Introduction o Industrial Revolution o Domino Theory o Heinrich s Theorems o Modern Causation Model o Swiss Cheese Model o Conclusion

3 Back Ground Air Ambulance Emergency Medical Service is a very demanding and time critical/mission orientated operation. One consistent that needs to be addressed by each individual air ambulance organization is the safety of the flight crew, medical crew, patient passengers and support personnel.

4 Introduction The purpose of this period of instruction is to: Explain accident causation Discuss the accident prevention benefits of causation Discuss pro-active vs. re-active accident prevention Discuss system safety and its relationship to causation

5 In order to successfully design and manage an effective accident prevention program, it is first necessary to understand what causes accidents.

6 OK So. Why do accidents happen?

7

8 Cowboy before OSHA

9 Cowboy after OSHA

10 Safety Beginnings

11 Later a more sophisticated view was accepted- the person injured was somehow at fault. He was at fault because he should be "Punished", was careless", or just "stupid."

12 During the early industrial revolution, factory managers reasoned that workers, who were injured, were hurt because they weren t "careful." Accidents were considered a natural side effect of production; in other words, the cost of doing business. There was no way to change human nature, people always had been and always would be careless.

13 The court system upheld the view of individual responsibility for safety. The injured worker had to sue, and to win, the employer had to be found completely to blame for negligence, and this was rare. Public opinion rose against the "worker alone-is-to-blame" theory. The courts responded by being more responsive to workers' claims. State legislatures followed suit and by 1908 every state had an employer's liability law.

14 Employers now with financial responsibility for an injured worker began to see that financially at least, it would be more cost effective to prevent accidents. The only theory of what caused accidents was personal carelessness. Individual businesses and factories used a hit-or-miss kind of effort in designing a safety program. These efforts enjoyed varying degrees of effectiveness.

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

16 Accident Models

17 First Came. Mr. H.W. Heinrich

18 The Heinrich model to accident causation has been the basic approach in accident prevention and has been used mostly by safety societies and professional people since its publication in This was the first scientific approach.

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

20 Heinrich s Theorems 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.

21 Heinrich s Theory Corrective Action Sequence (The three E s) Engineering Education Enforcement

22 Example of Engineering out a hazard Before controls of exposure hazards After controls were applied to exposure hazards

23 Modern Causation Model OPERATING ERROR MISHAP (POSSIBLE) RESULT: -No damage or injury -Many fatalities -Major damage

24 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.

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

26 Modern Concept System defects Single Most Important Concept Yet Developed in Accident Prevention Theory!

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

28 Examples Systems defects include: Improper assignment of responsibility Improper climate/culture or motivation Inadequate training and education Inadequate equipment and supplies Improper procedures for the selection & assignment of personnel Improper allocation of funds

29 Eighty percent of needlestick injuries occur during device use or after use before disposal. OSHA mandates the use of needleless and engineered sharps injury protection systems to further isolate or remove the bloodborne pathogens hazards. You contact the staff for involvement in the device selection and evaluation process, which is an important element to achieving a reduction in sharps injuries, particularly as new safer devices are introduced into the work setting. Problem solved Right??? Example

30 SYSTEM DEFECTS Modern Causation Model OPERATING ERRORS Operating Errors occur because people make mistakes, but more importantly, they occur because of MISHAP (POSSIBLE) RESULT: -No damage or injury -Many fatalities -Major damage SYSTEM DEFECTS

31 Modern Causation Model The next question is, "What causes systems defects?" The answer is management errors, because managers are the people who design systems. In organizations without a safety staff, the buck stops with the manager. MANAGEMENT ERROR SYSTEM DEFECT OPERATING ERRORS MISHAP RESULT NO DAMAGE OR INJURY MAJOR DAMAGE MANY FATALITIES

32 Modern Causation Model Managers design the Systems MANAGEMENT ERROR SYSTEM DEFECTS OPERATING ERRORS System defects occur because of MISHAP (POSSIBLE) RESULT: -No damage or injury -Many fatalities -Major damage MANAGEMENT ERROR

33 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

34 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

35 Modern Causation Model SAFETY MANAGEMENT ERROR SAFETY PROGRAM DEFECT MANAGEMENT ERROR SYSTEM DEFECT OPERATING ERROR MISHAP RESULTS

36 The Near Miss RESULTS Could be Injury or No Injury

37 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 nearmisses. INITIAL STUDIES RECENT STUDIES 1 SERIOUS 1 SERIOUS 29 MINOR 59 MINOR 300 NEAR MISS 600 NEAR MISS

38 The Near Miss? What is a near miss? How do you identify a near miss? How do you use the near miss to prevent accidents?

39 There are seven avenues through which we can initiate countermeasures. None of these areas overlap. They are: Seven Avenues Safety management error Safety program defect Management error System defect Operating error Mishap Result

40 Seven Avenues Potential countermeasures for each modern causation approach include: 1 SAFETY MANAGEMENT ERROR TRAINING EDUCATION MOTIVATION TASK DESIGN

41 Seven Avenues Potential countermeasures for each modern causation approach include: 2 1 SAFETY PROGRAM DEFECT REVISE INFORMATION COLLECTION ANALYSIS IMPLEMENTATION

42 Seven Avenues Potential countermeasures for each modern causation approach include: MANAGEMENT ERROR TRAINING EDUCATION MOTIVATION TASK DESIGN

43 Seven Avenues Potential countermeasures for each modern causation approach include: SYSTEM DEFECT DESIGN REVISION VIA-- - SOP - REGULATIONS - POLICY LETTERS - STATEMENTS

44 Seven Avenues Potential countermeasures for each modern causation approach include: OPERATING ERROR 6 7 ENGINEERING TRAINING MOTIVATION

45 Seven Avenues Potential countermeasures for each modern causation approach include: MISHAP 7 PROTECTIVE EQUIPMENT BARRIERS SEPARATION

46 Seven Avenues Potential countermeasures for each modern causation approach include: RESULT CONTAINMENT FIREFIGHTING RESCUE EVACUATION FIRST AID

47 Accident Near Miss Cost Indirect Cost Souls Lesson Learned How Often? (Opportunities for Intervention)

48 Swiss Cheese Model How Accidents Happen The Swiss Cheese Model

49 How Accidents Happen The Swiss Cheese Model A safety system is made up of layers of protective barriers slices of cheese Holes in the cheese = weaknesses in the individual barriers Accidents happen when holes (weaknesses) momentarily align

50 Swiss Cheese in Action Driving a Vehicle

51 Swiss Cheese in Action Driving a Vehicle Weaknesses

52 Swiss Cheese in Action Driving a Vehicle Flat tire Heavy Brake traffic failure Icy road Text messaging Drunk driving KNOWN Weaknesses Sharp turn Steep hill

53 Swiss Cheese in Action Driving a Vehicle Flat tire Heavy Brake traffic failure Icy road Text messaging UNKNOWN Weaknesses Drunk driving Sharp turn Steep hill

54 Swiss Cheese in Action Driving a Vehicle Flat tire Heavy Brake traffic failure Icy road Text messaging Drunk driving Sharp turn Weaknesses Steep hill

55 Swiss Cheese in Action Driving a Vehicle Flat tire Heavy Brake traffic failure Icy road Drunk driving Sharp turn Weaknesses Steep hill

56 Your Role in Safety: Catch Small Deviations Early and Respond Properly Most of our safety systems have multiple layers of protection No layer is perfect Continuous attention to detail Catch small weaknesses early After an accident, it is common to find prior issues Missed signals, dismissed alerts Report close calls and near misses to help prevent serious accidents

57 That s all well and good but how do we put it to use? What s our goal anyway?

58 Theory and application of Accident Prevention Trends and Trend Analysis Systems Defects and applied solutions Proactive accident prevention strategies

59 Theory and application of Accident Prevention Trends and Trend Analysis What is a trend? How can we identify them? How do we use the information to prevent accidents?

60 Theory and application of Accident Prevention Trends and Trend Analysis What is a trend? Webster - The general course or prevailing tendency Aviation Experience They are like occurrences And they don t have to be accidents!

61 Theory and application of Accident Prevention Trends and Trend Analysis How can we identify them? One thing is for sure You can t ID them from your office. Trends are not only near misses. Any report or identified hazard should be recorded and tracked.

62 Near Miss Log Date Organization Aircraft Vehicle Individual Event Log it or Risk forgetting it

63 Theory and application of Accident Prevention Trends and Trend Analysis How do we use the information to prevent accidents? 1 st realize that you have discovered the problem before an accident that s called? proactive!!!! Then investigate and/or analyze it until you determine where the system defect exist Next implement a systemic solution and develop a follow-up assessment plan

64 Conclusion Causation is a science of why accidents happen. Systems Defect not just focus on deficiency. Near Miss that s where the safety pros make their money in accident prevention.

65 Questions